Life-Insurance Quote Form

Life-Insurance Quote Form
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E-mail*
Phone Number*

Area Code Phone Number
State*
Birth Date*

Month Day Year
Height*
example: 6'1''
Approximate Weight*
example: 110lbs
Amount of Insurance Needed*

$1,000,000$500,000$450,000$400,000$350,000$300,000$250,000$200,000$100,000$75,000$50,000$25,000$15,000$10,000$5,000
What monthly premium payment is affordable for you?*

$10-$50$51-$100$100 or more
Health Questions
Please "CLICK" your medications
No Medications

CLICK HERE
Diabetes

MetforminSulfonylureasMeglitinidesThiazolidinedionesDPP-4inhibitorsGLP-1receptor AgonistsSGLT2inhibitorsInsulin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
BloodThinners

Rivaroxaban (Xarelto)Dabigatran (Pradaxa)Apixaban (Eliquis)Heparin (various)Warfarin (Coumadin)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

AspirinClopidogrel (Plavix®)DipyridamolePrasugrel (Effient)Ticagrelor (Brilinta)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Cholesterol

StatinsAtorvastatin (Lipitor)Rosuvastatin (Crestor)Lovastatin (Advicor)Cholesterol Absorption InhibitorsEzetimibe/Simvastatin (Vytorin)Lanoxin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
High Blood Pressure

Amlodipine (Norvasc, Lotrel)Diltiazem (Cardizem CD, Cardizem SR, Dilacor XR,Tiazac)Felodipine (Plendil)Isradipine (DynaCirc, DynaCirc CR)Nicardipine (Cardene SR)Nifedipine (Adalat CC, Procardia XL)Nisoldipine (Sular)Verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Stroke

CoumadinJantovenPlavixAtorvastatin (Lipitor)Fluvastatin (Lescol)Lovastatin (Altoprev)Pitavastatin (Livalo)Pravastatin (Pravachol)Rosuvastatin (Crestor)Simvastatin (Zocor)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril (Lotensin)Captopril (Capoten)Enalapril (Vasotec)Fosinopril (Monopril)Lisinopril (Prinivil, Zestril)Moexipril (Univasc)Perindopril (Aceon)Pravastatin (Pravachol)Quinapril (Accupril)Ramipril (Altace)Trandolapril (Mavik)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
ARBs or Angiotensin-2 Receptor Antagonists

Candesartan (Atacand)Eprosartan (Teveten)Irbesartan (Avapro)Losartan (Cozaar)Telmisartan (Micardis)Valsartan (Diovan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Beta-Adrenergic Blocking Agents

Acebutolol (Sectral)Atenolol (Tenormin)Betaxolol (Kerlone)Bisoprolol/hydrochlorothiazide (Ziac)Bisoprolol (Zebeta)Metoprolol (Lopressor, Toprol XL)Nadolol (Corgard)Propranolol (Inderal)Sotalol (Betapace)Carvedilol (Coreg)Labetalol Hydrochloride (Normodyne, Trandate)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Calcium Channel Blockers

Amlodipine (Norvasc, Lotrel)Atenolol (Tenormin)Felodipine (Plendil)Nifedipine (Adalat, Procardia)Nimodipine (Nimotop)Nisoldipine (Sular)Verapamil (Calan, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Water Pills

Amiloride (Midamor)Bumetanide (Bumex)Chlorothiazide (Diuril)Chlorthalidone (Hygroton)Furosemide (Lasix)Hydro-chlorothiazide (Esidrix, Hydrodiuril)Indapamide (Lozol)Spironolactone (Aldactone)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Vasodilators (Nitrates)

Isosorbide dinitrate (Isordil)Nesiritide (Natrecor)Chlorothiazide (Diuril)Hydralazine (Apresoline)NitratesMinoxidil
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
HIV/Aids

Abacavir or ABC (Ziagen)Didanosine or ddl (Videx)Emtricitabine or FTC (Emtriva)Lamivudine or 3TC (Epivir)Stavudine or d4T (Zerit)Tenofovir Alafenamide or TAF (Vemlidy)Tenofovir Disoproxil fumarate, or TDF (Viread)Zidovudine or ZDV (Retrovir)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Other Medications (Not Listed)
Marketing Initiative (Click ALL that apply)

Acts of Grace Bible CollegeChurch/MinistryCommunity Service Group
Please verify that you are human*
2nd Applicant
Full Name

First Name Middle Name Last Name
E-mail
example@example.com
Phone Number

Area Code Phone Number
State
Birth Date

Month Day Year
Height
example: 6'1''
Approximate Weight
example: 110lbs
Amount of Insurance Needed

$250,000$100,000$75,000$50,000$25,000$15,000$10,000$5,000
What monthly premium payment is affordable for you?

$10-$50$51-$100$100 or more
Health Questions
Please "CLICK" your medications
No Medications

CLICK HERE
Diabetes

MetforminSulfonylureasMeglitinidesThiazolidinedionesDPP-4inhibitorsGLP-1receptor AgonistsSGLT2inhibitorsInsulin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
BloodThinners

Rivaroxaban (Xarelto)Dabigatran (Pradaxa)Apixaban (Eliquis)Heparin (various)Warfarin (Coumadin)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

AspirinClopidogrel (Plavix®)DipyridamolePrasugrel (Effient)Ticagrelor (Brilinta)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Cholesterol

StatinsAtorvastatin (Lipitor)Rosuvastatin (Crestor)Lovastatin (Advicor)Cholesterol Absorption InhibitorsEzetimibe/Simvastatin (Vytorin)Lanoxin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
High Blood Pressure

Amlodipine (Norvasc, Lotrel)Diltiazem (Cardizem CD, Cardizem SR, Dilacor XR,Tiazac)Felodipine (Plendil)Isradipine (DynaCirc, DynaCirc CR)Nicardipine (Cardene SR)Nifedipine (Adalat CC, Procardia XL)Nisoldipine (Sular)Verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Stroke

CoumadinJantovenPlavixAtorvastatin (Lipitor)Fluvastatin (Lescol)Lovastatin (Altoprev)Pitavastatin (Livalo)Pravastatin (Pravachol)Rosuvastatin (Crestor)Simvastatin (Zocor)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril (Lotensin)Captopril (Capoten)Enalapril (Vasotec)Fosinopril (Monopril)Lisinopril (Prinivil, Zestril)Moexipril (Univasc)Perindopril (Aceon)Pravastatin (Pravachol)Quinapril (Accupril)Ramipril (Altace)Trandolapril (Mavik)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
ARBs or Angiotensin-2 Receptor Antagonists

Candesartan (Atacand)Eprosartan (Teveten)Irbesartan (Avapro)Losartan (Cozaar)Telmisartan (Micardis)Valsartan (Diovan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Beta-Adrenergic Blocking Agents

Acebutolol (Sectral)Atenolol (Tenormin)Betaxolol (Kerlone)Bisoprolol/hydrochlorothiazide (Ziac)Bisoprolol (Zebeta)Metoprolol (Lopressor, Toprol XL)Nadolol (Corgard)Propranolol (Inderal)Sotalol (Betapace)Carvedilol (Coreg)Labetalol Hydrochloride (Normodyne, Trandate)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Calcium Channel Blockers

Amlodipine (Norvasc, Lotrel)Atenolol (Tenormin)Felodipine (Plendil)Nifedipine (Adalat, Procardia)Nimodipine (Nimotop)Nisoldipine (Sular)Verapamil (Calan, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Water Pills

Amiloride (Midamor)Bumetanide (Bumex)Chlorothiazide (Diuril)Chlorthalidone (Hygroton)Furosemide (Lasix)Hydro-chlorothiazide (Esidrix, Hydrodiuril)Indapamide (Lozol)Spironolactone (Aldactone)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Vasodilators (Nitrates)

Isosorbide dinitrate (Isordil)Nesiritide (Natrecor)Chlorothiazide (Diuril)Hydralazine (Apresoline)NitratesMinoxidil
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
HIV/Aids

Abacavir or ABC (Ziagen)Didanosine or ddl (Videx)Emtricitabine or FTC (Emtriva)Lamivudine or 3TC (Epivir)Stavudine or d4T (Zerit)Tenofovir Alafenamide or TAF (Vemlidy)Tenofovir Disoproxil fumarate, or TDF (Viread)Zidovudine or ZDV (Retrovir)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Other Medications (Not Listed)
Marketing Initiative (Click ALL that apply)

Acts of Grace Bible CollegeChurch/MinistryCommunity Service Group
3rd Applicant
Full Name

First Name Middle Name Last Name
E-mail
example@example.com
Phone Number

Area Code Phone Number
State
Birth Date

Month Day Year
Height
example: 6'1''
Approximate Weight
example: 110lbs
Amount of Insurance Needed

$250,000$100,000$75,000$50,000$25,000$15,000$10,000$5,000
What monthly premium payment is affordable for you?

$10-$50$51-$100$100 or more
Health Questions
Please "CLICK" your medications
No Medications

CLICK HERE
Diabetes

MetforminSulfonylureasMeglitinidesThiazolidinedionesDPP-4inhibitorsGLP-1receptor AgonistsSGLT2inhibitorsInsulin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
BloodThinners

Rivaroxaban (Xarelto)Dabigatran (Pradaxa)Apixaban (Eliquis)Heparin (various)Warfarin (Coumadin)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

AspirinClopidogrel (Plavix®)DipyridamolePrasugrel (Effient)Ticagrelor (Brilinta)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Cholesterol

StatinsAtorvastatin (Lipitor)Rosuvastatin (Crestor)Lovastatin (Advicor)Cholesterol Absorption InhibitorsEzetimibe/Simvastatin (Vytorin)Lanoxin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
High Blood Pressure

Amlodipine (Norvasc, Lotrel)Diltiazem (Cardizem CD, Cardizem SR, Dilacor XR,Tiazac)Felodipine (Plendil)Isradipine (DynaCirc, DynaCirc CR)Nicardipine (Cardene SR)Nifedipine (Adalat CC, Procardia XL)Nisoldipine (Sular)Verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Stroke

CoumadinJantovenPlavixAtorvastatin (Lipitor)Fluvastatin (Lescol)Lovastatin (Altoprev)Pitavastatin (Livalo)Pravastatin (Pravachol)Rosuvastatin (Crestor)Simvastatin (Zocor)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril (Lotensin)Captopril (Capoten)Enalapril (Vasotec)Fosinopril (Monopril)Lisinopril (Prinivil, Zestril)Moexipril (Univasc)Perindopril (Aceon)Pravastatin (Pravachol)Quinapril (Accupril)Ramipril (Altace)Trandolapril (Mavik)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
ARBs or Angiotensin-2 Receptor Antagonists

Candesartan (Atacand)Eprosartan (Teveten)Irbesartan (Avapro)Losartan (Cozaar)Telmisartan (Micardis)Valsartan (Diovan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Beta-Adrenergic Blocking Agents

Acebutolol (Sectral)Atenolol (Tenormin)Betaxolol (Kerlone)Bisoprolol/hydrochlorothiazide (Ziac)Bisoprolol (Zebeta)Metoprolol (Lopressor, Toprol XL)Nadolol (Corgard)Propranolol (Inderal)Sotalol (Betapace)Carvedilol (Coreg)Labetalol Hydrochloride (Normodyne, Trandate)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Calcium Channel Blockers

Amlodipine (Norvasc, Lotrel)Atenolol (Tenormin)Felodipine (Plendil)Nifedipine (Adalat, Procardia)Nimodipine (Nimotop)Nisoldipine (Sular)Verapamil (Calan, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Water Pills

Amiloride (Midamor)Bumetanide (Bumex)Chlorothiazide (Diuril)Chlorthalidone (Hygroton)Furosemide (Lasix)Hydro-chlorothiazide (Esidrix, Hydrodiuril)Indapamide (Lozol)Spironolactone (Aldactone)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Vasodilators (Nitrates)

Isosorbide dinitrate (Isordil)Nesiritide (Natrecor)Chlorothiazide (Diuril)Hydralazine (Apresoline)NitratesMinoxidil
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
HIV/Aids

Abacavir or ABC (Ziagen)Didanosine or ddl (Videx)Emtricitabine or FTC (Emtriva)Lamivudine or 3TC (Epivir)Stavudine or d4T (Zerit)Tenofovir Alafenamide or TAF (Vemlidy)Tenofovir Disoproxil fumarate, or TDF (Viread)Zidovudine or ZDV (Retrovir)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Other Medications (Not Listed)
Marketing Initiative (Click ALL that apply)

Acts of Grace Bible CollegeChurch/MinistryCommunity Service Group
4th Applicant
Full Name

First Name Middle Name Last Name
E-mail
example@example.com
Phone Number

Area Code Phone Number
State
Birth Date

Month Day Year
Height
example: 6'1''
Approximate Weight
example: 110lbs
Amount of Insurance Needed

$250,000$100,000$75,000$50,000$25,000$15,000$10,000$5,000
What monthly premium payment is affordable for you?

$10-$50$51-$100$100 or more
Health Questions
Please "CLICK" your medications
No Medications

CLICK HERE
Diabetes

MetforminSulfonylureasMeglitinidesThiazolidinedionesDPP-4inhibitorsGLP-1receptor AgonistsSGLT2inhibitorsInsulin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
BloodThinners

Rivaroxaban (Xarelto)Dabigatran (Pradaxa)Apixaban (Eliquis)Heparin (various)Warfarin (Coumadin)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

AspirinClopidogrel (Plavix®)DipyridamolePrasugrel (Effient)Ticagrelor (Brilinta)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Cholesterol

StatinsAtorvastatin (Lipitor)Rosuvastatin (Crestor)Lovastatin (Advicor)Cholesterol Absorption InhibitorsEzetimibe/Simvastatin (Vytorin)Lanoxin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
High Blood Pressure

Amlodipine (Norvasc, Lotrel)Diltiazem (Cardizem CD, Cardizem SR, Dilacor XR,Tiazac)Felodipine (Plendil)Isradipine (DynaCirc, DynaCirc CR)Nicardipine (Cardene SR)Nifedipine (Adalat CC, Procardia XL)Nisoldipine (Sular)Verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Stroke

CoumadinJantovenPlavixAtorvastatin (Lipitor)Fluvastatin (Lescol)Lovastatin (Altoprev)Pitavastatin (Livalo)Pravastatin (Pravachol)Rosuvastatin (Crestor)Simvastatin (Zocor)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril (Lotensin)Captopril (Capoten)Enalapril (Vasotec)Fosinopril (Monopril)Lisinopril (Prinivil, Zestril)Moexipril (Univasc)Perindopril (Aceon)Pravastatin (Pravachol)Quinapril (Accupril)Ramipril (Altace)Trandolapril (Mavik)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
ARBs or Angiotensin-2 Receptor Antagonists

Candesartan (Atacand)Eprosartan (Teveten)Irbesartan (Avapro)Losartan (Cozaar)Telmisartan (Micardis)Valsartan (Diovan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Beta-Adrenergic Blocking Agents

Acebutolol (Sectral)Atenolol (Tenormin)Betaxolol (Kerlone)Bisoprolol/hydrochlorothiazide (Ziac)Bisoprolol (Zebeta)Metoprolol (Lopressor, Toprol XL)Nadolol (Corgard)Propranolol (Inderal)Sotalol (Betapace)Carvedilol (Coreg)Labetalol Hydrochloride (Normodyne, Trandate)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Calcium Channel Blockers

Amlodipine (Norvasc, Lotrel)Atenolol (Tenormin)Felodipine (Plendil)Nifedipine (Adalat, Procardia)Nimodipine (Nimotop)Nisoldipine (Sular)Verapamil (Calan, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Water Pills

Amiloride (Midamor)Bumetanide (Bumex)Chlorothiazide (Diuril)Chlorthalidone (Hygroton)Furosemide (Lasix)Hydro-chlorothiazide (Esidrix, Hydrodiuril)Indapamide (Lozol)Spironolactone (Aldactone)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Vasodilators (Nitrates)

Isosorbide dinitrate (Isordil)Nesiritide (Natrecor)Chlorothiazide (Diuril)Hydralazine (Apresoline)NitratesMinoxidil
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
HIV/Aids

Abacavir or ABC (Ziagen)Didanosine or ddl (Videx)Emtricitabine or FTC (Emtriva)Lamivudine or 3TC (Epivir)Stavudine or d4T (Zerit)Tenofovir Alafenamide or TAF (Vemlidy)Tenofovir Disoproxil fumarate, or TDF (Viread)Zidovudine or ZDV (Retrovir)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Other Medications (Not Listed)
Marketing Initiative (Click ALL that apply)

Acts of Grace Bible CollegeChurch/MinistryCommunity Service Group
5th Applicant
Full Name

First Name Middle Name Last Name
E-mail
example@example.com
Phone Number

Area Code Phone Number
State
Birth Date

Month Day Year
Height
example: 6'1''
Approximate Weight
example: 110lbs
Amount of Insurance Needed

$250,000$100,000$75,000$50,000$25,000$15,000$10,000$5,000
What monthly premium payment is affordable for you?

$10-$50$51-$100$100 or more
Health Questions
Please "CLICK" your medications
No Medications

CLICK HERE
Diabetes

MetforminSulfonylureasMeglitinidesThiazolidinedionesDPP-4inhibitorsGLP-1receptor AgonistsSGLT2inhibitorsInsulin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
BloodThinners

Rivaroxaban (Xarelto)Dabigatran (Pradaxa)Apixaban (Eliquis)Heparin (various)Warfarin (Coumadin)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

AspirinClopidogrel (Plavix®)DipyridamolePrasugrel (Effient)Ticagrelor (Brilinta)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Cholesterol

StatinsAtorvastatin (Lipitor)Rosuvastatin (Crestor)Lovastatin (Advicor)Cholesterol Absorption InhibitorsEzetimibe/Simvastatin (Vytorin)Lanoxin
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
High Blood Pressure

Amlodipine (Norvasc, Lotrel)Diltiazem (Cardizem CD, Cardizem SR, Dilacor XR,Tiazac)Felodipine (Plendil)Isradipine (DynaCirc, DynaCirc CR)Nicardipine (Cardene SR)Nifedipine (Adalat CC, Procardia XL)Nisoldipine (Sular)Verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Stroke

CoumadinJantovenPlavixAtorvastatin (Lipitor)Fluvastatin (Lescol)Lovastatin (Altoprev)Pitavastatin (Livalo)Pravastatin (Pravachol)Rosuvastatin (Crestor)Simvastatin (Zocor)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril (Lotensin)Captopril (Capoten)Enalapril (Vasotec)Fosinopril (Monopril)Lisinopril (Prinivil, Zestril)Moexipril (Univasc)Perindopril (Aceon)Pravastatin (Pravachol)Quinapril (Accupril)Ramipril (Altace)Trandolapril (Mavik)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
ARBs or Angiotensin-2 Receptor Antagonists

Candesartan (Atacand)Eprosartan (Teveten)Irbesartan (Avapro)Losartan (Cozaar)Telmisartan (Micardis)Valsartan (Diovan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Beta-Adrenergic Blocking Agents

Acebutolol (Sectral)Atenolol (Tenormin)Betaxolol (Kerlone)Bisoprolol/hydrochlorothiazide (Ziac)Bisoprolol (Zebeta)Metoprolol (Lopressor, Toprol XL)Nadolol (Corgard)Propranolol (Inderal)Sotalol (Betapace)Carvedilol (Coreg)Labetalol Hydrochloride (Normodyne, Trandate)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Calcium Channel Blockers

Amlodipine (Norvasc, Lotrel)Atenolol (Tenormin)Felodipine (Plendil)Nifedipine (Adalat, Procardia)Nimodipine (Nimotop)Nisoldipine (Sular)Verapamil (Calan, Verelan)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Water Pills

Amiloride (Midamor)Bumetanide (Bumex)Chlorothiazide (Diuril)Chlorthalidone (Hygroton)Furosemide (Lasix)Hydro-chlorothiazide (Esidrix, Hydrodiuril)Indapamide (Lozol)Spironolactone (Aldactone)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Vasodilators (Nitrates)

Isosorbide dinitrate (Isordil)Nesiritide (Natrecor)Chlorothiazide (Diuril)Hydralazine (Apresoline)NitratesMinoxidil
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
HIV/Aids

Abacavir or ABC (Ziagen)Didanosine or ddl (Videx)Emtricitabine or FTC (Emtriva)Lamivudine or 3TC (Epivir)Stavudine or d4T (Zerit)Tenofovir Alafenamide or TAF (Vemlidy)Tenofovir Disoproxil fumarate, or TDF (Viread)Zidovudine or ZDV (Retrovir)
Date of your Diagnosis

MonthDay Year
Date
Dosage (Mg)
Other Medications (Not Listed)
Marketing Initiative (Click ALL that apply)

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Health Questions

Health Questions

Health Questions

Health Questions

Health Questions