Stroke Questionnaire

Stroke (Cerebrovascular Accident) Questionnaire

SECTION I: AGENT INFORMATION
Full Name of Agent:
Agent's Phone Number
Agent's Fax Number
Agent's E-mail

SECTION II: CLIENT BACKGROUND INFORMATION
Client's Name
Date Of Birth:
Sex:	Male Female
Smoker:	Smoker Non-smoker
If history of smoking, date stopped?:
Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.)
Type of product:
Face amount requested?
Premium Range Desired? (If replacement, list current premium and face amount)

SECTION III: CLIENT MEDICAL INFORMATION
Prior company action? (Name of company, rating, premium)
Type of medical impairment or other underwriting problem?
Date condition was first diagnosed?
Current height and weight? (If weight has changed in the last 12 months, please indicate)
Current blood pressure readings?
Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day)
Is client currently seeing a doctor for listed condition? Date of last visit?
Types and dates of surgery or hospital treatment?
Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer?
Any other medical history?

SECTION IV: STROKE (Cerebrovascular Accident)QUESTIONS
Definition: Any impairment of the brain or spinal cord that occurs as a result of a blood vessel disorder. This can be either a CVA (Cerebrovascular Accident, Cerebral Infarction, Cerebral Hemorrhage), or a TIA (Transient Ischemic Attack). A CVA is an interruption of the flow of blood to the brain from abnormalities of occlusion, clogging of vessels, or spasms for a period of more than 24 hours. A TIA is a temporary interruption of the arterial blood supply to a part of the brain.
What type of disorder was your client diagnosed or suspected of having? (ie: stroke or TIA)
Did your client have single or multiple episodes? If multiple episodes, give date of first episode, date of last episode, and total number of episodes?
What parts of the body were affected?
Are there any Residual Impairments? Side effects? If “Yes,” details.
Are there complicating factors? (ie: Coronary Artery Disease, Diabetes, Hypertension) Give details.

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