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Exercise Prescription Form

THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 2 - FEBRUARY 96


Return to Commentary: Exercise is Medicine

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:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Follow up in ___________ weeks

Physician: ___________________________________ Date: ___________


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