Name: Section: Schedule: Date:

Exercise Prescription Form

Instruction: Design your own fitness plan by filling out this form.
E.g. Exercise 1: Push Ups Duration: 1 minute Reps: 10 Sets: 2

● Cardiovascular Conditioning
✔ Warm-Up:
Exercise 1: _ Duration: _ mins. Reps: _ Sets:
Exercise 2: _ Duration: _ mins. Reps: _ Sets:
Exercise 3: _ Duration: _ mins. Reps: _ Sets:
Exercise 4: _ Duration: _ mins. Reps: _ Sets:

● Muscular Resistance Training

✔ Conditioning:
Exercise 1: _ Duration: _ mins. Reps: _ Sets:
Exercise 2: _ Duration: _ mins. Reps: _ Sets:
Exercise 3: _ Duration: _ mins. Reps: _ Sets:
Exercise 4: _ Duration: _ mins. Reps: _ Sets:
Exercise 5: _ Duration: _ mins. Reps: _ Sets:
Exercise 6: _ Duration: _ mins. Reps: _ Sets:
Exercise 7: _ Duration: _ mins. Reps: _ Sets:
Exercise 8: _ Duration: mins. Reps: _ Sets:
Exercise 9: _ Duration: _ mins. Reps: _ Sets:
Exercise 10: Duration: mins. Reps: Sets:

a. Frequency: x a week (put check on the day/s below)

Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday
 Name: Section: Schedule: Date:

b. Intensity: (check your risk stratification)

Low Risk Moderate to High Intensity
Moderate Risk Low to Moderate Intensity
High Risk Low Intensity

c. Time: min/session min/week

d. Type: (check the exercises you will include in your program)

Cardiovascular
Muscular Strength
Walking
Push Ups
Brisk Walking Curl Up
Running Lunges
Biking Squat
Dancing Lifting Weights

Others:

✔ Cool Down:
Exercise 1: _ Duration: _ mins. Reps: _ Sets:
Exercise 2: _ Duration: _ mins. Reps: _ Sets:
Exercise 3: _ Duration: _ mins. Reps: _ Sets:
Exercise 4: _ Duration: _ mins. Reps: _ Sets: