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Exercise Prescription Form: Name: Section: Schedule: Date

This document is an exercise prescription form that allows a user to design their own fitness plan. It includes sections to fill out details for stretching, warm-up exercises, cardiovascular conditioning, muscular resistance training, conditioning exercises, and cool down exercises. The form also includes sections to specify exercise frequency, intensity, time, and type based on risk stratification. The goal of the form is to help a user create a customized fitness plan.

Uploaded by

Aaron Torres
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104 views2 pages

Exercise Prescription Form: Name: Section: Schedule: Date

This document is an exercise prescription form that allows a user to design their own fitness plan. It includes sections to fill out details for stretching, warm-up exercises, cardiovascular conditioning, muscular resistance training, conditioning exercises, and cool down exercises. The form also includes sections to specify exercise frequency, intensity, time, and type based on risk stratification. The goal of the form is to help a user create a customized fitness plan.

Uploaded by

Aaron Torres
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Name: Date:

Section: Schedule:

Exercise Prescription Form


Instruction: Design your own fitness plan by filling out this form.

 Stretching: Duration :_____mins


 Cardiovascular Conditioning
Example: Exercise 1: Jogging Duration : 10 mins. Reps: 1 Sets: 1

 Warm-Up:
Exercise 1:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 2:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 3:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 4:______________________ Duration :_____mins. Reps:______ Sets:______

 Muscular Resistance Training


Example: Exercise 1: Push Ups Duration : 3 mins. Reps: 5 Sets: 3

 Conditioning:
Exercise 1:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 2:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 3:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 4:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 5:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 6:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 7:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 8:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 9:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 10:______________________ Duration :_____mins. Reps:______ Sets:______

This document is the property of PHINMA


EDUCATION
Name: Date:
Section: Schedule:

a. Frequency: _______x a week (put check on the day/s below)


Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday

b. Intensity: (check your risk stratification)


______Low Risk -> Moderate to High Intensity
______Moderate Risk -> Low to Moderate Intensity
______High Risk -> Low Intensity

c. Time: _____min/session ______min/week

d. Type: (check the exercises you will include in your program)


Cardiovascular Muscular Strength
_____Walking _____Push Ups
_____Brisk Walking _____Curl Up
_____Running _____Lunges
_____Biking _____Squat
_____Dancing _____Lifting Weights

Others:______________________________________________________________________

 Cool Down:
Exercise 1:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 2:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 3:______________________ Duration :_____mins. Reps:______ Sets:______
Exercise 4:______________________ Duration :_____mins. Reps:______ Sets:______

This document is the property of PHINMA


EDUCATION

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