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Please fill out the form below.
Note: All information provided in this form is strictly private and confidential.

Date
Name
Address
City
State/Province
Zip code
Age (yrs)
Height (ft, in)
Weight (lbs)
Date of Birth (mm/dd/yyyyy)
Home Phone
Work Phone
Cell Phone
E-mail
Emergency Contact
Contact Phone

How did you hear about our program?

Assess your health status by marking all true statements:

History
I have had the following (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

Syptoms
(please check all that apply):
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
(please check all that apply):
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
(please check all that apply):

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?

Yes No

Average number of hours per week 

What activities do you participate in?


Thank you!

*Note: The COCC Exercise Physiology Lab is NOT a medical facility and firmly adheres to the current American College of Sports Medicine Guidelines pertaining to cardiovascular disease risk factors which states: If a person has two or more risk factors they should have a medical examination prior to testing. We reserve the right to refuse testing until the client provides us with a written clearance from his/her physician.

Copyright Central Oregon Community College
Last revised: April 14, 2008