Exercise Prescription and Referral Form

Name :____________________ NRIC:____________________ Age :_________

Date :____________________ Risk Level ⎕LOW ⎕MODERATE ⎕ HIGH

Referral to Health Fitness Professional :

____________________________________

Address:___________________________

Appointment Date:_________________

Exercise Goals : ____________________

Medical Conditions :

⎕ Hypertension ⎕ Dyslipidaemia

⎕ Obesity ⎕ Diabetes Mellitus

⎕ Others_____________________________

Medications:__________________________

RX: Aerobic Exercise :

Type

How many times a week

Intensity / target heart rate

Number of minutes each day

Total number of minutes per week

Resistance Exercise:________________________________________________________

Others:_____________________________________________________________________

Remarks/Special Precautions:_______________________________________________

Physician Signature & Name : ___________________________

Clinic Address:

Tel:

Fax:

Email: