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.
Date:
Monday, November 26, 2012 
Name
Address
City State Zip
Age Height Weight
Phone-Home Phone-Work Phone-Cell
Email Address
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)
Symptoms
Other heath issues
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?
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 Cheryl Pitkin: cpitkin@cocc.edu or call 541-383-7768.