Exercise Prescription Form
THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 2 - FEBRUARY 96
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Exercise Prescription
Patient name: ___________________________________________________________
Current fitness needs:_____________________________________________________
Goal:
A. Optimal fitness level
B. Markedly improved fitness level
C. Measurably improved fitness level
Precription
Aerobic exercise (type): ______________________________________________
Additional exercise (types): ___________________________________________
Frequency (days per week): ___________________________________________
Duration (minutes): _________________________________________________
Intensity (mild, moderate, strenuous): ___________________________________
Notes:
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_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Follow up in ___________ weeks
Physician: ___________________________________ Date: ___________
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