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Exercise Physiology Lab Medical History Form


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Central Oregon Community College

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.

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Assess your health status by marking all true statements:

History
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
   Stroke
   Heart Failure
   Heart Transplant
   Congenital Heart Disease
  

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).
  

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: cpitkin@cocc.edu or call 541-383-7768.