EIM PA Prescription Form

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Name: ____________________________ Date: ______________ 2018 Physical Activity Guidelines for Adults: • 150-300 minutes/week of moderate-intensity activity or 75-150 minutes/week of vigorous activity (somewhat hard to very hard) or a combination of both • Muscle strength training 2 or more times a week Aerobic Activity (check) Frequency (days/week): q 1 q 2 q 3 q 4 q 5 q 6 q 7 Intensity: q Light (casual walk) q Moderate (brisk walk) q Vigorous (like jogging) Time (minutes/day): q 10 q 20 q 30 q 40 q 50 q 60 or more Type: q Walk q Run q Bike q Swim/Water Exercise q Other ______________ Steps/day: q 2,500 q 5,000 q 7,500 q 10,000 or more q Other ________________ What about aerobic activity? • Moderate activity is at a pace where you can talk but cannot “sing.” Examples: brisk walking, light biking, water exercise and dancing. • Vigorous activity is done at a pace where you cannot talk and may be out of breath. Examples: jogging, swimming, tennis and fast bicycling. • You can exercise for any length of time. For example, you might walk: • 30 minutes 5 days/week or • 20 minutes daily • 5 minutes here, 10 minutes there. Just work your way up to 150 total minutes/week. • Your ultimate goal is to gradually build up to 7,500-10,000 steps/day. Muscle Strength Training (check) Frequency (days/week): q 1 q 2 q 3 q 4 q 5 q 6 q 7 What about strength training? • You don’t have to go to a gym. Try elastic bands, do body weight exercises (chair sit-to- stands; floor, wall or kitchen counter push-ups; planks or bridges) or lift dumbbells. Heavy work around your home or yard also builds strength. • Strengthen your legs, back, chest and arms. To start, try 10-15 repetitions using light effort. Build up to medium or hard effort for 8-12 repetitions. Repeat 2-4 times, 2-3 days/week. • Give yourself a rest day between each strength training session. Prescriber’s Signature: How will you get started this week?.

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Y Balance Test™Anterior Reach Symmetry At
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