If your client has a pacemaker, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date when the implant was installed ? 


   2.  The pacemaker was implanted for :
       Heart Block Associated with Coronary Artery Disease
       Complete Heart Block or Sick Sinus Syndrome
       Chronic Underlying Atrial Flutter/Fibrillation
       Other, give details


   3.  If your client has other heart disease,
       give details: 


   4.  Have any of the following pacemaker complications ocurred ?
       Infection
       Pacemaker Mulfunction
       Blood Clots
       Perforation
       Other, give details


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 

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


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

       (example: heart disease, etc.)

       If yes, give details: