Central Oregon Community College Exercise Physiology Lab Medical History Form (Page 2 of 2) in pdf

Other heath issues

_______ I have diabetes.

_______ I have asthma or other lung disease.

_______ 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) listed 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 Factors

_______ 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 total blood cholesterol level of >200 mg/dL.

_______ I do not know my blood cholesterol level.

_______ I take blood cholesterol 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.

Please explain any other significant medical problems that you consider important for us

to know, for example HIV +, Hepatitis…

________________________________________________________________________

Are you currently involved in a regular exercise program? _________________

Average number of hours per week ____________

What activities do you participate in?

________________________________________________________________________

THANK YOU!

Central Oregon Community College Exercise Physiology Lab Medical History Form Page 2