Stroke Questionnaire

        

                                                                          

                                                                                             

                                                                                             

                                                                                             

Approximate date of first stroke?                                       

How many strokes have you had?                                     

                                                                                                             
                                                                                    

                                                                                             

 

                                                                                             

                                                                                          

Full name:                                                                                     

Phone no:                                                                            

Email address:                                                                     

Best time to be contacted:                                                

 

 

       

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Special Risk Managers Pty Ltd is a member firm and corporate authorised representative of Count Financial Limited ABN 19 001 974 625 AFSL 227232

Date of Birth:
Height:
Weight:
Type of insurance you want:

What treatment did/do you receive? 

Approximate date of last stroke?
Approximate date and result of last blood pressure reading?
Approximate date and result of last cholesterol test?
Do you have any other health issues?
Have you smoked in the last 12 months?