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Run: Home Exercise Program Prescription and Delivery

Home Exercise Program Prescription and Delivery template for documenting prescribed exercises, dosage, patient education, demonstration, and patient understa...

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Visit and Patient Context

Patient Identifier (required)

Enter the patient ID or chart number used in your system. Do not enter a full SSN or other unnecessary PII.

Visit Date (required)

Discipline (required)

How was the home exercise program delivered? (required)

If other, describe the delivery method

Prescribed Exercises

Prescribed Exercises (required)

Intensity or effort guidance

Enter any pain-free range, resistance, pace, or effort guidance provided.

Precautions or stop criteria

Document any symptoms, movements, or conditions that should stop the exercise and prompt follow-up.

Patient Education and Understanding

Education topics covered (required)

Did the patient demonstrate the exercises? (required)

Demonstration quality

Patient understanding confirmed (required)

Education notes

Document any teach-back, questions answered, or follow-up instructions provided. Include only minimum necessary details.

Follow-Up and Attestation

Follow-up plan

Enter the next visit plan, reassessment timing, or instructions for contacting the clinic.

Patient acknowledgment of receipt

Yes No N/A

Clinician Name (required)

Clinician Signature (required)

Get your results

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Email (required)

Your name (optional)

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