Impaired Risk
Stroke Questionnaire
Agent Information
Agent Name
Address
Phone
Fax
E-Mail
LMG Marketing Rep:
Client Information
Client's name
Date of birth
mm
dd
yy
Sex
M
F
Height
Feet
2 '
3 '
4 '
5 '
6 '
7 '
8 '
9 '
Inches
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs.)
Smoker
Yes
No
(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type
Select one
Term
UL
Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied
mm
yy
Company
Declined
Postponed
Rated table
1. Date of first stroke
mm
yy
2. How many strokes have occurred in the last 24 months?
select one
None
1
2 or more
3. Has client ever had a carotid artery surgery as a result of a stroke?
Yes
No
If yes, when mm
yy
4. Does client have any of the following residual neurological deficits?
Slurred speech
Loss of use of limb
Restricted use of limb
Other
5. Date of last stress EKG
mm
yy
6. Date and result of last cholesterol reading
reading
mm
yy
7. Date and result of last blood pressure reading
reading
mm
yy
8. How many times per week does client exercise?
select one
None
1 time per week
2 times per week
3 times per week
4 times per week
5 times per week
6 times per week
7 times per week
More than 7
Type of exercise
9. Are there any other illnesses/impairments?
10. What medications are currently being taken?
11. Has either parent, or any sibling, died before age 65, other than by accident?
Yes
No (If yes, list relationship(s) and cause)
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
Additional Information