Health Fitness Plan printable pdf download

Health Fitness Plan

For Use Upon Discharge From Physical/Occupational Therapy

Name of Participant: ________________________________________________________

Name of Therapist: _________________________________________________________

Instructions: Thank you for utilizing the Health Fitness Plan. This form serves two purposes. First, this form

will be used to indicate appropriate exercises for you upon discharge from PT/OT services and secondly, to

facilitate communication between the PT/OT and local health fitness professional.

TO THE CLIENT: This form is intended to be utilized to outline appropriate exercises based on your current

health status and based on what we know now. If you experience a change in your health status, these rec-

ommendations may no longer be valid and you must take appropriate action. That means it is up to you to

seek out further medical attention either from your primary care physician or any other specialist that is

needed. Please be advised that the PT/OT will not be continuing on in your care upon discharge from our

facility. We recommend that you sit down with your physical or occupational therapist and outline an ap-

propriate fitness plan designed specifically for you by checking off the relevant boxes on the HFP form.

TO THE THERAPIST: Please fill out this form in consultation with your client by checking only the relevant

boxes for the participant. Consider educating your client with regard to indications for returning to a PT/OT

professional. Examples may include 6-month brace re-evaluation, anticipated wheelchair modifications for

seating clinic, increased activity tolerance, etc. By completing this Health Fitness Plan, you are not assuming

any responsibility for administration of the exercise program. If you know of any medical or other reasons

why participation in an exercise program by the applicant would be unwise/unsafe, please indicate so on

this form. For your convenience, equipment that does not require a transfer have been marked as depicted:

Participant is responsible for entering the gym independently OR

with one’s own personal assistant (PCA, family)

NOTE TO THERAPIST: A medical clearance should be received from a medical doctor to clear the individual

to participate in FES and/or a Standing Frame program.

I, ____________________________ (Name of Participant), give my Therapist permission to report per this

form and subsequently share with an appropriate health and fitness facility (not just the YMCA), any perti-

nent medical issues that I have that may affect my participation in any exercise program or activity.

Signature of Participant _____________________________

Date: ______________________

Signature of PT/OT_________________________________

Date: ______________________

Participant or Caregiver should bring completed form to appropriate exercise facility

Health Fitness Plan