Stroke/TIA Questionnaire

DATE

ADVISOR NAME

PHONE

FAX

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

HEIGHT

WEIGHT

TOBACCO USE

Yes No Quit

QUIT WHEN?

OTHER COMPANY ACTIONS:

Rated

Postponed Declined

OTHER COMPANY DETAILS:

DATE OF FIRST STROKE:

DATE OF LAST STROKE:

NUMBER OF STROKES WITHIN THE LAST 24 MONTHS:

APPROXIMATE DATE OF LAST EKG:

LAST CHOLESTEROL READING:

LAST BLOOD PRESSURE READING:

HAS PROPOSED INSURED EVER HAD A TIA (TRANSIENT ISCHEMIC ATTACK)?

NO YES

DOES PROPOSED INSURED HAVE ANY OF THE FOLLOWING RESIDUAL NEUROLOGICAL DEFICITS?

SLURRED SPEECH

LOSS OF USE OF LIMB

RESTRICTED USE OF LIMB

OTHER

HAS THE PROPOSED INSURED HAD A CAROTID ARTERY SURGERY AS A RESULT OF A STROKE?

NO YES

IF YES, YEAR?

DOES PROPOSED INSURED REGULARLY EXERCISE THREE OR MORE TIMES PER WEEK?

NO YES

IF YES - PLEASE PROVIDE DETAILS:

PLEASE LIST ANY OTHER ILLNESS OR IMPAIRMENT:

PLEASE LIST ANY MEDICATIONS BEING TAKEN AND THEIR DOSAGE:

HAS EITHER PARENT OR ANY SIBLING DIED BEFORE AGE 65, OTHER THAN BY ACCIDENT?

NO YES

IS PROPOSED INSURED CURRENTLY EMPLOYED OR CAPABLE OF BEING EMPLOYED?

NO YES

ADDITIONAL COMMENTS:

The form was sent successfully.

An error occured.

Life Insurance Nerds

Life Insurance Nerds

Life Insurance Nerds

Client Information