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Download Atrial and Ventricular Septal Defects
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Atrial and Ventricular Septal Defects Ask the “PFG” Underwriter Producer___________________________ Phone____________________ Fax_________________ Client______________________________ Age/DOB_________________ Sex_________________ If your client has had ASD or VSD, please answer the following: 1. Please list the date of diagnosis:_____________________________ 2. Please check type of septal defect? ASD, ostium secundum or sinus venosus VSD, small ASD, primum VSD, moderate VSD, large 3. Has surgical repair(s) been completed? Yes, please give details __________________________________________________ No 4. Are any other congenital defects present? Yes, cardiac, please give details ___________________________________________ Yes, non cardiac, please give details ________________________________________ 5. 6. 7. 8. No Please check if any of the following have occurred: Heart enlargement Bundle branch block on ECG Pulmonary hypertension Arrythmia Is your client on any medications? Yes, please give details __________________________________________________ No Has your client smoked cigarettes in the last 12 months? Yes, please give details __________________________________________________ No Does your client have any other major health problems (ex: cancer, etc.)? Yes, please give details __________________________________________________ No
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