Central Oregon Community College Exercise Physiology Lab Medical History Form printable pdf download

Central Oregon Community College Exercise Physiology Lab Medical History Form

Central Oregon Community College

Exercise Physiology Lab

Medical History Form

All information is private and confidential

Date _____________

Name ________________________________________________________________________

Address ______________________________________________________________________

City ________________ State __________ Zip _________

Age _______ Height _______ Weight _______ Date of Birth _________

Phone-Home _____________ Work ____________ Cell ____________

Email Address _______________________________________

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:

_______ 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).

Central Oregon Community College Exercise Physiology Lab Medical History Form