Exercise Physiology Lab Medical History Form

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Medical History Form

Central Oregon Community College
Exercise Physiology Lab
Website: http://www.cocc.edu/exphyslab/

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.

Date:

Name (first and last):

Address:

City:

State:

Zip Code:

Age:

Height:

Weight (lbs.):

Phone (main):

Phone (other):

Email:

Emergency Contact Name:

Emergency Contact Phone:

How did you hear about our program?

What would you like to gain from this test?

Assess your health status by marking all true statements:

History
I have had: (please check all that apply)

Comments - Please list any other important history information:

Symptoms

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).

Comments - Please list any other symptom information:

Other heath issues

I have diabetes.

I have burning or cramping sensations in my lower legs when walking short distances.

I have musculoskeletal problems that limit my physical activity.

I have concerns about the safety of exercise.

I am pregnant.

I take the prescription medication(s).

Please list any prescription medications here:

** 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

Please explain any other significant medical problems that you consider important for us to know, for example HIV +, Hepatitis etc.

Are you currently involved in a regular exercise program? Yes/No

Average number of hours per week:

What activities do you participate in?

Before submitting, you may wish to print this page for your records.

If you have questions please contact John Liccardo: jliccardo@cocc.edu or call 541-318-3754.

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