WellnessCenter
Exercise Prescription: Physical Activity Questionnaire
In order for the Wellness Center Staff to make an Exercise Prescription for you, we would like to obtain some information before your appointment.
Name __Carolyn______Phone __333-4444______Age __75____
For each question below, please mark YES or NO.YES NO
1. I currently participate in moderate physical activity: 30+ minutes of activity/day. A. B.
2. I intend to increase my participation in moderate physical activity in thenextC. D.
six months.
3. I currently engage in regular moderate physical activity:30+ minutes/day andE. F.
at least five days/week.
4. I have been participating in moderate physical activity regularly for theG. H.
past six months.
5. I am not currently active, but in the past, I have been regularly physically active I. J.
in moderateactivities for a period of at least three months.
Current weight _115______
How many days per week are you planning on exercising? ____7______
How many minutes per day are you planning on exercising? ___45-60______
My current exercise routine is:
Cardiovascular Exercise:____30______min/day ______7_____days / wk
Weight Training Exercise: ____0______min/day _____ 0_____days / wk
Flexibility Exercise:____0______min/day ______0_____days / wk
My health improvement / exercise goals are:
To improve my current exercise routine by adding in strength exercises. I had a double mastectomy two years ago and my upper body strength has greatly decreased. ______
The advantages to me achieving these goals are:
I will be able to continue to do the activities I enjoy for as long as possible. I want to be able to pick up my grandkids again.
Currently the following barriers get in the way of meeting my health improvement or exercise goals:
The skin on my chest is very sensitive to any pressure or stretching. I don’t know the appropriate exercises or machines to use without causing pain or discomfort. My reach is very limited on the right arm due to the removal of lymph nodes. ___
In the future, I plan to work around these barriers by:
Utilize the exercise professional to accommodate my limitations and create a strength routine that will not cause additional discomfort on my chest.
Exercise Prescription: Physical Activity Questionnaire – Cheat Sheet
Name __Carolyn______Phone __333-4444______Age __75____
General:
With strength routines, many individuals who have had a mastectomy are uncomfortable with leaning forward against the chest pads that are standard on machines such as the Sitting Row and Preacher Curl. Generally, participants do not have problems on chest press machines aside from muscle weakness.
Strength:
Back Exercises: Standing or Sitting Row using a cable pulley machine or exercise band. (replacing the Upper Back machine)
Bicep Exercises: Bicep Curls using a cable pulley machine, exercise band, or dumbbells (replacing the Preacher Curl machine)
Flexibility:
Chest Stretches: Swan Stretch, Single Arm Chest Fliess (no resistance)
Under Arm Stretches: Finger Walking (up the wall), Alternate Overhead Reaches (could also use a pulley)
Professionally managed by the National Institute for Fitness and Sport