If your client has an Aortic Valve Disorder, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  How long has this abnormality been present ? 


   2.  Type(s) of Aortic Valve Disorders present ? (check all that apply)
        Mitral Stenosis
        Mitral Insufficiency
        Mitral Valve Lapse


   3.  Have any of the following ocurred?
       Chest Pain                    Yes   No 

       Palpatations                  Yes   No 

       Trouble Breathing             Yes   No 

       Atrial Fibrillation/Flutter   Yes   No 

       Heart Failure                 Yes   No 


   4.  Is there a history of any other heart disease in addition
       to the aortic valve disorder ? Yes   No 

       (problems with other valves, coronary artery disease, etc.)

       If yes, give details: 


   5.  Have additional studies been completed ?
        Echocardiogram              Date
        Cardiac Catheterization	    Date
        None


   6.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   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: