If your client has a history of irregular heart beat, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Is the atrial fibrillation/flutter
        Premature Supraventricular Atrial Beats (PAC's)
        Premature Ventricular Beats (PVC's)
        Chronic Atrial Flutter or Fibrillation (AF)
        Paroxysmal Atrial Flutter or Fibrillation (AF)


   3.  Have any of the following ocurred ?
       Black-Out
       Dizzyness (light-headedness)/Faint Feeling
       Palpitations
       Chest Discomfort


   4.  Have any of the following tests been done ? If so, please provide date and results :
       ECG              Date   Results 
       Echocardiogram   Date   Results 
       Stress Test      Date   Results 
       Holter Monitor   Date   Results 


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 

   6.  The cause of the atrial fibrillation/flutter is due to :
       Heart Disease
       Thyroid Disease
       Alcohol
       Unknown or Other


   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: