BLOOD PRESSURE



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:

  • When diagnosed:
  • Type of treatment:
    Weight Loss
    Salt Reduction
    Medication (list type)
  • Type of medication and dosage:
  • Does client take medications regularly?
    Yes No
  • Is blood pressure controlled currently?
    Yes No
  • Last reading:
  • Any complications?
  • Has an electrogram been done?
    Yes No
  • Additional Comments: