Stroke – TIA or CVA Questionnaire - Tentative offers obtained are not binding and could be subject to change – Final offers
are subject to formal application and review of all required age/face requirements, paramedical requirements and review of complete medical records.
2633 E. Indian School Road, Suite 410
Phoenix, Arizona 85016
P: 602-494-9500 P: 800-516-0283
F: 602-494-0500
Agent/Advisor Name: _____________________________________
Proposed Insured: _________________________ Date Of Birth: ____________ Gender: Male☐ or ☐Female
Build: Height_______ Weight______ Any Weight Loss In Last Year? If so how much _________
Product Desired: Term ☐ Guarantee UL☐ Index UL☐ Whole Life☐Survivorship Life ☐
Face Amount Desired: Option 1 $____________ Option 2 $___________ Option 3$_____________
Maximum Premium Tolerance Per Year: _______________ Has Client Ever Used Any Form Of Nicotine? No ☐ Yes ☐
Type: ☐ Cigarettes ☐ Cigars ☐ Pipe ☐ Chew ☐ Patch ☐ Nicorette Gum ☐ E-Cigarette ☐ Vape
Frequency: ________ Date Last Used_______
Current Alcohol Use: Type__________ Number of Drinks: _____ Per _____Day ____Week Date Last Used: _________
1) What was date of stroke? _____________ Were you hospitalized? ☐Yes ☐No If yes; provide
details:____________________________________________________________________________________
2) Was it diagnosed as TIA (Transient Ischemic Attack) or CVA (Cerebrovascular Accident)? ☐TIA ☐CVA
3) What follow up studies were done following the stroke (CVA) or mini stroke (TIA)? Please check all that apply:
☐CT Scan Date_______ ☐MRI Scan Date________ ☐Carotid ultrasound/Doppler Date:_______
☐Echocardiogram Date:_________☐Stress Test Date:_________ ☐Other_________________ Date:_______
4) Was this the first (ONLY) occurrence? ☐Yes ☐No If not; when were prior instances?
___________________________________________________________________________________________
Was cause of the stroke determined? ☐Yes ☐No If yes; provide complete details
___________________________________________________________________________________________
___________________________________________________________________________________________
5) Is there any residual neurologic or cognitive impairments? ☐Yes ☐No If yes; provide complete details
___________________________________________________________________________________________
__________________________________________________________________________________________
6) Do you currently have or ever had any history of CAD (Coronary Artery Disease), PVD (Peripheral Vascular
Disease), diabetes, hypertension or smoking? ☐Yes ☐No If yes; provide details “yes” to a CT or MRI, carotid
Doppler and street test are required for review for accurate assessment
___________________________________________________________________________________________
___________________________________________________________________________________________
7) Have you been diagnosed with any of the following conditions? ☐Hypertension-Avg. BP: ____ /_____
☐Peripheral vascular disease ☐Kidney/renal disease ☐Internal carotid artery stenosis ☐Left ventricular
hypertrophy ☐Cardiomyopathy ☐Diabetes-Avg. A1c: ____ ☐ Atrial fibrillation ☐Coronary artery disease
8) Do you exercise three or more times per week on a regular basis? ☐Yes ☐No If yes; provide details
___________________________________________________________________________________________
9) Have you made any lifestyle changes to improve your overall health? ☐Yes ☐No If yes; provide details
___________________________________________________________________________________________
10) Are you being treated for any other medical conditions? If yes; provide details
___________________________________________________________________________________________
11) Is there family history of heart disease or cancer? ☐Yes ☐No If yes; provide details including relationship to
yourself, age of onset, type and current age or date of death
__________________________________________________________________________________________
12) When did you last see your physician for evaluation and what were results?
___________________________________________________________________________________________
13) Please list all current medications, dosages and what condition the medication is treating
___________________________________________________________________________________________
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