Exercise Planning Form

Setting goals

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:

Community resource

Contact information

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:

Exercise goals

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:

How often:_______________

How long:________________

Strength and balance exercises I will do:

How often:_______________

How long:________________

Flexibility exercises I will do:

How often:_______________

By Healthwise Staff
Primary Medical Reviewer Adam Husney, MD - Family Medicine
Last Revised September 6, 2013

Last Revised: September 6, 2013

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