Exercise Prescription Format

Patient Information

Full Name:	____________________
Age:	____________________
Gender:	____________________
Contact Number:	____________________

Medical History and Considerations

Please select any of the following medical conditions that apply:

• Cardiovascular Disease

• Diabetes

• Hypertension

• Asthma

• Other (please specify): __________

Exercise Goals

Indicate the primary goals for the exercise program:

• Weight Loss

• Muscle Gain

• Improving Cardiovascular Fitness

• Flexibility and Mobility

• Rehabilitation

• Other (please specify): __________

Exercise Plan

Outline the designated exercise routine:

Exercise	Frequency	Duration	Intensity
____________________	____________________	____________________	____________________
____________________	____________________	____________________	____________________
____________________	____________________	____________________	____________________

Additional Notes

____________________________________________________________________________________________

____________________________________________________________________________________________

Please review the form carefully and ensure that all information is correct before submission.

Prescribed by: [YOUR NAME]

Signature: ___________________________

Date: _________________________________

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