ExERCISE PRESCRIPTION FORM
1. Shoulder Press:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
2. Chest Press:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
3. Shoulder Rows:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
4. Elbow Extension:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
5. Elbow Flexion:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
6. Standing hip Abduction:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
7. Standing hip Extension:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
8. External Rotation:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
9. Shoulder hold-Up:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
10. Sitting Knee Flexion:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
11. Sitting Knee Extension:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
12. Trunk Rotation
(sitting)
:
Freq:_____ Sets:_____ reps:______
Notes ______________________________________________________________
13. lunges:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
14. Trunk Rotation
(standing)
:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
15. hip Flexion:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
16. Abdominal Crunch:
Freq:_____ Sets:_____ reps: ______
Notes ______________________________________________________________
Resistance
Thin
Medium
heavy
Extra heavy Special heavy
Color
Yellow
Red
Green
Blue
Black
15.24 cm
.31 kg
.73 kg
.90 kg
1.40 kg
2.30 kg
30.48 cm
.57 kg
1.40 kg
1.60 kg
2.40 kg
4.10 kg
45.72 cm
.79 kg
1.80 kg
2.10 kg
3.20 kg
4.90 kg
60.96 cm
.91 kg
2.22 kg
2.70 kg
3.90 kg
6.10 kg
76.20 cm
1.00 kg
2.50 kg
3.10 kg
4.50 kg
7.00 kg
91.44 cm
1.20 kg
2.70 kg
3.40 kg
5.10 kg
8.60 kg
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