If your client has a history of hypertension, please answer the following :
1. Date of first diagnosis ?
What was the most recent blood pressure reading ?
(client may need to contact their physician's office for this information)
2. Is your client on any medication ? Yes No If yes, give details:
3. Has the client had any of the following ? (check all that apply)
Chest Pain or Coronary Artery Disease
Family History of Heart Disease, High Blood Pressure, Stroke
TIA or Stroke
Peripheral Vascular Disease
4. Has a stress electrocardiogram (treadmill test) been completed within the past year ?
Yes - Normal Date
Yes - Abnormal Date
5. Has your client smoked cigarettes in the last 12 months ? Yes No
6. Does your client have any major health problems ? Yes No (example: heart disease, etc.)
If yes, give details:
The underwriter will respond back to you
on this case within 48 hours.