ANGINA

Please complete the following information:
* Indicates a required field
    Broker Information:
    Broker Name: *

    Phone: *

    Fax: *

    Email: *

    Address: *

    City: *

    State: *

    Zip: *

    Client Information:
    Insured's Name:

    Date of Birth:

    Sex:
    Male Female
    Type of Policy:

    State(s):

    Nicotine User:
    YES NO
    If YES: Cigarette Cigar Other:

    If NO: Number of years without:

  • Frequency of attacks:
  • Date of last attack:
  • Was hospitalization required?:
    YES NO
  • Type of medication and dosage:
  • Currently using nitroglycerin?
    YES NO
  • Has the client ever had a stress EKG (a treadmill, bicycle, or medication induced stress test)?
    Yes No
  • Was a thallium or stress echo test done?
    Yes No
    If Yes, When: Results:
  • Was a cardiac catheterization (or an angiogram) done?
    Yes No
    If Yes, When:
  • Any restrictions?
  • Any testing done?
  • Additional Comments: