If your client has had coronary bypass surgery, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of the heart attack ? 


   2.  Has the client had any of the following ? (check all that apply)
       Echocardiogram               Date
       Coronary Catheterization     Date
       Coronary Angioplasty (PTCA)  Date
       Heart Failure                Date
       Bypass Surgery               Date
       Arrythmias                   Date


   3.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   4.  Has a follow-up stress (exercise) ECG been completed since the heart attack ?
        Yes - Normal    Date
        Yes - Abnormal  Date
        No


   5.  Has your client has any chest discomfort since the heart attack ? Yes   No 

       If yes, give details: 


   6.  Has the client had any of the following ? (check all that apply)
       Elevated Cholesterol
       Diabetes
       Overweight
       High Blood Pressure
       Family History of Heart Disease


   7.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   8.  Does your client have any major health problems ? Yes   No 

       (example: heart disease, etc.)

       If yes, give details: