Activity Prescription And Patient Log

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Activity Prescription and Patient Log
This form is used by a health care provider to prescribe specific activities that will promote healing and
recovery. The part at the bottom is used by the patient to log the activities and record information to
share with the provider at the next visit. The third page should be duplicated with enough copies to
allow logging of activities every day until the next visit. Keeping track of the activities and how the
patient feels before and after doing them will help the provider and patient plan changes in activities as
recovery progresses. The patient should also record other activities that were not specifically
prescribed.
Example:
Activity Prescription
Activity
How Often
How Long Each Time?
Special Instructions
Go for a walk
Twice a day
At least 10 minutes
Increase the time
gradually
McKenzie back
3 times a day
As long as it takes
exercises
for full set
 Start today
 Start tomorrow
 Start ____________
Patient Log
Date:
_____
3/18
Time of
Activity
How
Feelings Before
Feelings After
Day
Long?
Noon
Walk
7 min
Scared
Tired
2:30
McKenzie back
20 min
Pain, sore
A little better
PM
exercises
8:30
McKenzie back
20 min
Sore, tired
Sore, tired
PM
exercises
Date:
_____
3/19
Time of
Activity
How
Feelings Before
Feelings After
Day
Long?
7 AM
Walk
10 min
A little sore
More energy
7:20
McKenzie back
20 min
Pain, sore
Better
AM
exercises
Noon
Walk
12 min
Determined
Pretty good; less pain
2:30
McKenzie back
20 min
Some pain
Pain about the same
PM
exercises
9 PM
McKenzie back
20 min
Sore, pain in right
Still sore but pain in
exercises
leg
leg gone

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