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Exercise Physiology Lab Medical History Form

* = required field
Central Oregon Community College

Medical History Form

Central Oregon Community College
Exercise Physiology Lab

All information is private and confidential 
If you would prefer to use a print form see
Medical History Print Form (pdf) 

Please fill out the form below as thoroughly as possible.


Assess your health status by marking all true statements:

I have had: (please check all that apply)

Heart attack
Coronary Artery Bypass Grafting
Cardiac Catheterization
Angioplasty (PTCA), Coronary Stent(s)
Pacemaker/Implantable cardiac defibrillator
Heart Arrhythmia
Heart Valve disease/defect
Heart Failure
Heart Transplant
Congenital Heart Disease


I experience chest discomfort with exertion.
I experience chest discomfort at rest.
I experience unreasonable breathlessness.
I experience dizziness, fainting, or blackouts.
I take heart medication(s).

Other heath issues

I have diabetes.
I have burning or cramping sensations in my lower legs when walking short distances.
I am pregnant.
I take the prescription medication(s).
** If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in physical exercise. You may need to be tested at a facility such as a hospital that monitors your heart rhythm or electrocardiogram.

Cardiovascular Risk Factor

I am a man older than 45 years.
I am a woman older than 55 years
I am a woman who has had a hysterectomy, or am postmenopausal.
I smoke or I quit smoking within the previous 6 months.
My blood pressure is =140/90 mmHg
I do not know my blood pressure.
I take blood pressure medication(s).
I have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister).
I am physically inactive, therefore I exercise <30 minutes on at least 3 days per week.
I am >20 pounds overweight.

Before submitting, you may wish to print this page for your records.
If you have questions please contact Cheryl Pitkin: or call 541-383-7768.