Planning exercise referral programmes with patients Adaptations to programme Patient’s name: Learner’s name: Date: Learner to patient feedback: Week no: Recommended Recommended Recommended exercise/activity (1) exercise/activity (2) exercise/activity (3) Description of environment Description of environment Description of environment Safety/environmental Safety/environmental Safety/environmental considerations (1) considerations (2) considerations (3) Frequency Frequency Frequency Intensity Intensity Intensity Time Time Time Weekly goal(s) Description of any equipment to be used:
Planning exercise referral programmes with patients Adaptations to programme Patient’s name: Learner’s name: Date: Learner to patient feedback: Week no: Recommended exercise/activity (1) Recommended exercise/activity (2) Recommended exercise/activity (3) Description of environment Description of environment Description of environment Safety/environmental considerations (1) Safety/environmental considerations (2) Safety/environmental considerations (3) Frequency Frequency Frequency Intensity Intensity Intensity Time Time Time Weekly goal(s) Description of any equipment to be used: