CIGI Direct Insurance Services, Inc. QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS

Transcription

1 QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS Amount of Insurance $ Type of Insurance 1. Has patient had: Date of last symptom, list date (or dates if more than one ) Angina pectoris (heart pain)? r Yes r No Myocardial infarction (heart attack)? r Yes r No 2. How often are heart symptoms (chest, arm, or neck discomfort, sense of chest pressure, etc.)? Number of times per month per year 3. Date of MOST RECENT treadmill (Stress) electrocardiogram Results: r Normal r Abnormal 4. Have you had or been advised to have: Cardiac catheterization (coronay angiography)? r Yes r No Coronary angioplasty (PTCA)? r Yes r No (If Yes, see Questionnaire on reverse side) Coronary artery bypass surgery? r Yes r No (If Yes, see Questionnaire on reverse side) 5. How long was patient out of work due to conditions in #2 #4 above? 6. List all medications below, including vitamin supplements, aspirin, allergy over-the -counter drugs or supplements. Include frequency dosage. 7. Does patient carry a pill to be placed under the tongue for chest discomfort? r Yes r No If Yes, date last used 8. Date of last blood pressure check: Results: 9. Date of last cholesterol check: Total Chol: HDL: 10. Exercise Activities: aerobics/muscle strengthening/toning Mo/Yr started Times/Week Duration 11. Diet Program Does patient check weight periodically to detect any change? r Yes r No Weight lbs. Height Does patient make any planned or supervised adjustments in eating habits to maintain a desirable weight? r Yes r No Within the past three years, has patient followed a controlled diet? r Yes r No If Yes, was it controlled with respect to: r Total calories r Cholesterol r Fats r Salt r Other Was information obtained from: r Nutritionist r Dietician r Physician r Your reading r Structured weight program

2 QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS 1. Which of the following procedures was completed? r Angioplasty r Coronary Bypass (If no Bypass performed, skip to #5.) 2. When was coronary bypass surgery performed? Date # of Grafts If second coronary bypass was performed, detail: Date # of Grafts 3. How old was patient when surgery was performed? Age 4. Indicate type of grafts used: r Saphenous vein (from legs) r Internal mammary artery r Both If no Angioplasty done, skip to #6 5. When was the coronary angioplasty performed? Date # of Arteries If second angioplasty was performed, detail: Date # of Arteries 6. Which conditions preceded the angioplasty or bypass? r Heart Attack r Chest Pain r Irregular stress EKG r Extreme Fatigue r Other 7. Since the coronary angioplasty or bypass, has the patient experienced any of the following: r Chest Pain r Irregular stress EKG r Neither 8. The date of the last doctor s visit: Frequency of visits: 9. The date of the last EKG: Frequency of EKG(s): 10. Please list ejection fraction if known: 11. Please list Left Ventricle End Diastolic Pressure, if known: 12. Please list any other illness or impairments: 13. Last life insurance application: Date Company Action Any additional information:

3 - QUICK QUOTE DIABETES Amount of Insurance $ Type of Insurance Height Weight 1. Age of onset of diabetes? 2. What is the method of control? r Diet only r Oral medication (List medication) r Insulin injection (type dosage) 3. How many times per day do you administer your insulin? r I am on an insulin pump r one or two times per day r three or more per day 4. How often do you monitor blood sugar levels? r one or two times per day r three or more per day 5. Average fasting glucose? 6. Recent range for fasting glucose (high/low)? 7. Please indicate below if you have had any of the following: r EKG abnormalities r Eye trouble r Heart trouble r Skin ulceration r Neuropathy or loss of feeling r Insulin reactions r Diabetic coma r Protein in urine r Amputations r Other Please explain any answers marked in 5: 8. Date of last Glycohemoglobin (HbA1c) test: Results: 9. How long as your Glycohemoglobin (HbA1c) level remained constant? r 0 to 6 months r 6 to 12 months r 13 months or more 10. List all medications below, including vitamin supplements, aspirin, allergy over-the -counter drugs or supplements. Include frequency dosage. 11. Last life insurance application: Date Company Action Any additional information:

4 - QUICK QUOTE CANCER Amount of Insurance $ Type of Insurance 1. Type of malignancy or cancer: (Attach copy of pathology report if available.) r Bladder r Colon or rectal (also complete question 9) r Prostate (also complete question 11) r Breast r Hodgkin s Disease r Skin* r Cervical r Melanoma* (also complete question 10) r Other * If Melanoma or skin were checked, please indicate type where on the body cancer was located: Type Location 2. Has tumor or malignancy metastasized? Month Year 3. Stage of tumor or malignancy: r 1 r 2 r 2A r 2B r 3 r 3A r 3B r 4 r 5 r Other Name of tumor or malignancy: 4. Treatment? Check all treatments that apply to case: r Surgical removal of malignancy r Chemo-therapy r Radiation therapy r Hormonal (Orchidectomy-Des. Lupron) r Other 5. When was last treatment received? Date Type 6. Has there been any medical evidence of recurrent cancer? r Yes r No Date 7. Please list any other illness or impairment, if any: 8. List all medications below, including vitamin supplements, aspirin, allergy over-the-counter drugs or supplements. Include frequency dosage. 9. Answer only if Colon or Rectal cancer are involved. r A1 r B1 r B2 r C1 r C2 r D 10. Answer only if Melanoma is involved. Clark s level: r I r II r III r IV r V Depth of Melanoma 11. Answer only if Prostate cancer is involved. Gleason s Grade: r I r II r III r IV r V r VI r VII r VIII What were the results of your recent PSA test? 12. Last life insurance application: Date Company Action Any additional information:

5 QUICK QUOTE ALCOHOL & SUBSTANCE USAGE Amount of Insurance $ Type of Insurance 1. Please note condition: r Alcohol abuse (Answer questions 2 through 6 9 through 13) r Drug or other substance abuse (Answer questions 7 through 13) 2. Do you currently consume any type of alcoholic beverages? r Yes r No If Yes, how often in what amounts? Details of past alcohol abuse: From: To: Amount: Frequency: 3. Are you currently a member of AA or a similar support group? r Yes r No 4. Within the last six years, list the occasion date(s) of driving under the influence (DUI s), arrests convictions. r None Dates 5. Results of your most recent liver function test: r Normal r Minimally elevated r Moderately elevated r Elevated Attach blood test results if available. 6. Are you presently taking, or have you taken antabase or any other medication to help control your drinking? r Yes r No If Yes, dates duration: 7. Are you using or have you ever in the past used the following substances or drugs: r Opiates/Narcotics: Heroin, Codeine, Morphine, Methadone, Demerol r Methamphetamine: Cocaine, Crack, Ice r Barbiturates: Amytal, Phenobarbital r Hallucinogens: LSD, Peyote, Psilocybin r Non-barbiturates: Placidyl, Doriden, Quaalude r Marijuana r Amphetamines: Benzedrine, Dexedrine r Other Substance Amount Frequency Date last used Substance Amount Frequency Date last used 8. Have you ever been arrested for possession, use, distribution of an illegal substance? r Yes r No 9. Have you ever been hospitalized, institutionalized or been an outpatient in an alcohol or substance abuse program? r Yes r No If Yes, please detail: Place: Admitted: Discharged: Place: Admitted: Place: Admitted: 10. Martial status: r Married r Single r Divorced Discharged: Discharged: Occupation: Employer Yrs. Previous Employer 11. Please list any other impairments: 12. Please list any all medications currently being taken: 13. Last life insurance application: Date Company Action Any additional information:

6 - QUICK QUOTE FOR OTHER ILLNESSES Amount of Insurance $ Type of Insurance Weight lbs. Height 1. Please list illness(es) details (note severity or each - mild, moderate or severe): 2. Give the date(s) the above illness was diagnosed: 3. What type of treatment was administered? r Surgery r Medication r Other 4. When was the last time you visited a physician? r 0-6 months ago r 6-12 months ago r months ago r Over 24 months ago 5. Date last cholesterol check: Total Chol: HDL: 6. Date of last blood pressure check: Results: 7. Exercise Activities: aerobics/muscle strengthening/toning Mo/Yr started Times/Week Duration 8. List all medications below, including vitamin supplements, aspirin, allergy over-the-counter drugs or supplements. Include frequency dosage. 9. Last life insurance application: Date Company Action 10. With the last three years have you been disabled? Date Duration Occupation 11. How much time lost from work in the last three years from work due to this condition? 12. Other significant information: