Bring this sheet with you when you visit your doctor. Working
together, you can use this sheet to develop your exercise program.
Special tests I need before begin an exercise program (if any):
My chronic health conditions are:
Exercises to help with these conditions are:
Exercises I should not do include:
Community resources and contacts (like the local YMCA) that might
be useful to me:
Personal supports (like family members or exercise partners) who
might help me include:
Other questions I have about beginning an exercise program are:
Warning signs I need to watch for are:
Other questions I have about beginning an exercise program:
Steps to take to get started include:
The three things I want to accomplish most by exercising are:
Physical activities I enjoy:
Physical activities I would like to try:
My initial exercise program will be:
Aerobic exercises I will do:
Strength and balance exercises I will do:
Flexibility exercises I will do:
September 6, 2013
Adam Husney, MD - Family Medicine
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