Heart. (a) Is there any cardiovascular disorder? [_] Yes [_] No (b) Is heart enlarged? [_] Yes [_] No (If yes, describe) (c) Is murmur present? [_] Yes [_] No (If yes, complete 15d) ------------------------------------------------------------------- (d) Murmur is: [_] Constant [_] Inconstant [_] Transmitted [_] Systolic [_] Apical [_] Soft (Gr. 1-2) [_] Localized [_] Presystolic [_] Basal [_] Mod. (Gr. 3-4) [_] Diastolic [_] Other [_] Loud (Gr. 5-6) After exercise [_] Unchanged [_] Increased [_] Decreased [_] Absent Show location of: Apex by [SYMBOL] Area of murmur by [SYMBOL] [GRAPHIC APPEARS HERE] Point of greatest intensity by [SYMBOL] Transmission by [SYMBOL]
Appears in 5 contracts
Samples: Pacific Select Exec Separate Acct Pacific Life Ins, Pacific Select Exec Separate Acct Pacific Life Ins, Pacific Select Exec Separate Acct Pacific Life Ins
