If your client has a history of CVA/Stroke, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date(s) of TIA(s) ? 


   2.  Were any of the following studies completed ?
       Carotid Ultrasound        (date)
       Head CT Scan or MRI Scan  (date)
       Echocardiogram            (date)


   3.  Is your client on any medications ? Yes   No 

       If yes, give details:  


   4.  Has your client had any of the following conditions ? (select all that apply)
       Elevated Cholesterol
       Diabetes
       High Blood Pressure
       Stroke
       Heart Attack
       Peripheral Vascular Disease
       Coronary Artery Disease


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


   6.  Has surgery ever been done on the carotid artery(ies) ? Yes   No 

       If yes, give details:  


   7.  Date and results of most recent blood pressure reading ? 


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

       (example: cancer, etc.)

       If yes, give details: