E X E R C I S E I S M E D I C I N E ™

Nurses’ Action Guide

www.ExerciseIsMedicine.org

E-mail: [email protected] • Phone: 317-637-9200

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HOW TO USE THE GUIDE

The Exercise is MedicineTM Nurses’ Action Guide provides nurses, nurse practitioners
and allied health care professionals with a simple, fast and effective tool for using
physical activity, in the right “dosage”, as a highly effective prescription for the
prevention, treatment, and management of more than 40 of the most common chronic
health conditions encountered in primary practice.

This guide acknowledges and respects that today’s modern health care professional has
limited time for exercise counseling during the normal office visit and empowers you,
depending on your skill level in exercise counseling, to either:

 Write an exercise prescription, depending on the health, fitness level, and

physical activity preferences of your patient, or

 Refer your patient to a certified health and fitness professional who specializes
in exercise counseling and will oversee your patient’s exercise under your
supervision.

Here’s how to get started:

1. Review How to Use the Guide, which you are currently reading. Once you have read
this, it is highly recommended that you read through the Exercise Prescription and
Referral Process document. This is the core of the guide and will explain how to
either quickly write a prescription for your patient or refer them to a certified health
and fitness professional.
2. Once you are comfortable with the prescription and referral process, use the
Exercise Prescription & Referral Form to either give your patient a physical activity
prescription or to refer them to a health and fitness professional.
3. If your patient is healthy, print out and give them a Starting an Exercise Program
Patient Handout.
4. If your patient has a chronic health condition, refer to the Your Prescription for Health
flier series. If your patient’s condition is included in this series, print out and give
them the appropriate patient handout on how to safely exercise with their condition.
This series has been reviewed by experts from the American College of Sports
Medicine.
5. Print out and display copies of the Office Flier in your waiting room, patient rooms
and any other locations you deem appropriate.

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PROGRAM FOR HEALTH

PRESCRIPTION & REFERRAL PROCESS

Dear Nurses and Allied Health Care Professionals,

One of most important decisions your patients will make regarding their overall
health is to incorporate physical activity into their lifestyle. Your encouragement
may be the greatest influence on this decision.

The algorithm given below will give you guidance in monitoring your patients and
helping them to exercise. It’s a simple and quick, but effective, three-step
process:
1. Find out about each patient’s current physical activity level.
2. Determine if your patient is healthy enough for independent exercise.
3. If your patient exercises less than the recommended level (as most
patients do), you’ll see how to quickly use the simplified Stages of Change
model described below to best help your patient.

These steps may be adjusted to fit the specific needs of your clinic or physicians'
office. There may be various types of health care professionals working together
with one patient. Work with your office staff and other in-office health care
professionals to create an appropriate procedure for exercise prescriptions and
referrals. Different factors, including the type and location of the heath and fitness
professional, office guidelines, time restrictions and the culture of the clinic or
office, dictate who must sign the exercise prescription and referral form.

Some patients will be ready only for encouragement; some will be prepared to
read the Starting an Exercise Program patient handout (page six); and some
will be willing to get an exercise prescription from you or obtain a referral to a
certified health and fitness professional as part of the Exercise is Medicine™
initiative. After you’ve read through the description below, you’ll find a template
exercise prescription form for use to copy and use with your patients.

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1. Ask patient if they currently exercise? (See recommended guidelines1)

If YES,

Type/s of Activity__________ How Hard? __________

How Long? _________ How Often? __________

Then go to Step 2.

If NO, ask why not, and determine if the patient is willing to start a lifestyle modification
program/exercise program?

If YES, go to step 2.

If NO, briefly discuss benefits of exercise with patient, provide educational handout
discussing such, and encourage patient to start adding extra activity/steps to their day, as
well as improving dietary choices, if need be. Schedule a nurse or other allied health care
professional to follow-up with patient in one week to see if patient is interested in starting
lifestyle modification program/exercise program. If YES, at follow-up, go to step 2.

2. Determine if patient is healthy enough to exercise independently, and determine the

appropriate actions necessary for exercise counseling and/or referral to a fitness
professional. See the Preparticipation Screening Flowchart (Appendix A) for a simple
step-by-step process.

Administer Physical Activity Readiness Questionnaire (see Appendix B): The Physical
Activity Readiness Questionnaire (PAR-Q), a screening/educational tool, focuses on
symptoms of heart disease while identifying musculoskeletal problems that should be
evaluated prior to participation in an exercise program.

If your patient answered NO to all of the PAR-Q questions, he or she may be cleared for
independent physical activity. If you clear your patient for independent physical activity, you
can write an exercise prescription based on the 2008 Physical Activity Guidelines for
Americans1. Alternatively, you may refer your patient to a fitness professional for
personalized exercise counseling. Apparently healthy patients who you clear for independent
exercise will still benefit from exercise counseling. In this case, you may refer your patient to
a non-clinical fitness professional2 such as a certified personal trainer or a health fitness
specialist.

If your patient answered YES to any of the PAR-Q questions, he or she may still be cleared
for independent or monitored physical activity. Use your professional judgment when deciding
whether a patient with a clinical condition can be cleared to exercise independently or
whether they need to exercise under the supervision of a clinical exercise professional2. If
you clear your patient for independent physical activity, you can write an exercise prescription
based on the 2008 Physical Activity Guidelines for Americans1, or you can refer your patient
to a fitness professional for exercise counseling. Patients with a clinical condition who you
clear for independent activity, just like apparently healthy patients, will still benefit from
exercise support and can be referred to a non-clinical fitness professional2 who is trained to
work with such individuals (for example, ACSM’s Health Fitness Specialist) or to a certified
personal trainer. Higher-risk patients with a disease who need supervised exercise should be
referred to a clinical exercise professional2 such as ACSM’s Registered Clinical Exercise
Physiologist or Clinical Exercise Specialist).

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3. Determine which stage of change (precontemplation, contemplation, preparation, or

action and maintenance) patient is in, and take appropriate action, as indicated in the
chart below.

Stage of Change Action

Precontemplation Encourage patient to consider exercising; tell patient
(Patient not ready to exercise) about health benefits of exercise.
Independent Supervision Necessary
Contemplation
(If patient interested in or Write prescription; refer
Refer to clinical exercise
to non-clinical fitness
thinking about exercising) 2,3 professional2,3
professional
Preparation Write prescription; refer
Refer to clinical exercise
(If patient exercising less than to non-clinical fitness
professional2,3
recommended amount1) professional 2,3

Action and Maintenance

Encourage continued Encourage continued
(If patient is exercising
exercise supervised exercise
recommended amount1)

4. Use the Exercise Prescription and Referral Form (see page 5/Appendix C) to write an
exercise prescription and/or referral, based the action determined from the chart in
step 3. If a referral is needed, the Physical Activity Clearance Form (see Appendix D)
may be filled out and given to the patient’s fitness or exercise professional.

For more information, visit www.exerciseismedicine.org.

1
Minimum of 150 minutes of moderate physical activity a week (for example, 30 minutes per day, five days a week) and
muscle-strengthening activities on two or more days a week (2008 Physical Activity Guidelines for Americans). Moderate
physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a
conversation. Examples: brisk walking, ballroom dancing or general gardening
2
It is highly recommended that you refer your patients only to fitness professionals who have been certified through an
NCCA-accredited association (click on “Accredited Certification Programs” at www.noca.org) such as the American
Council on Exercise (ACE), the American College of Sports Medicine (ACSM), the Cooper Clinic, the National Academy
of Sports Medicine (NASM), the National Strength and Conditioning Association (NSCA), or one of the seven other
accredited fitness associations (Academy of Applied Personal Training Education, International Fitness Professionals
Association, National Athletic Trainer’s Association Board of Certification, National Council on Strength and Fitness,
National Exercise and Sports Trainers Association, National Exercise Trainers Association, National Federation of
Professional Trainers).
3
The American College of Sports Medicine is currently developing a referral process to exercise professionals.

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E-mail: [email protected] • Phone: 317-637-9200
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HOW TO PRESCRIPTION EXERCISE
USE THE & REFERRAL PRESCRIPTION
PROCESS & REFERRAL
GUIDE
FORM

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STARTING AN YOUR OFFICE FLIER
EXERCISE PRESCRIPTION
PROGRAM FOR HEALTH

EXERCISE PRESCRIPTION & REFERRAL FORM

Available for download in PDF format at www.exerciseismedicine.org/nurses.htm.

Use the Exercise Prescription and Referral Form to write an exercise prescription and/or
referral, based the action determined from the Prescription & Referral Process. If a referral is
needed, the Physical Activity Clearance Form (see Appendix C) may be filled out and given
to the patient’s fitness or exercise professional.

www.ExerciseIsMedicine.org
5
E-mail: [email protected] • Phone: 317-637-9200
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HOW TO PRESCRIPTION EXERCISE
USE THE & REFERRAL PRESCRIPTION
PROCESS & REFERRAL
GUIDE
FORM

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STARTING AN YOUR OFFICE FLIER
EXERCISE PRESCRIPTION
PROGRAM FOR HEALTH

STARTING AN EXERCISE PROGRAM

Available for download in PDF format at www.exerciseismedicine.org/nurses.htm.

Starting an exercise program can sound like a daunting task, but just remember that
your main goal is to boost your health by meeting the basic physical activity
recommendations: 30 minutes of moderate-intensity physical activity at least five days
per week, or vigorous-intensity activity at least three days per week, and strength
training at least twice per week.

Guidelines for healthy adults under age 65 with no apparent chronic disease or
condition

STEP 1 — Set aside time each day to exercise. Getting started can often be the most
difficult part of any exercise routine. Scheduling exercise into your day and making it a
priority will increase the chance of being successful.

STEP 2 — Choose cardiovascular activities you enjoy, such as swimming, biking, or

playing basketball with friends, to get your daily physical activity. If you need a variety of
activities to stay motivated, combine a few that appeal to you. Physical activity can be
accumulated through a variety of activities. Walking is a great way to do moderate-
intensity physical activity. Moderate-intensity physical activity means working hard
enough to raise your heart rate and break a sweat, yet still being able to carry on a
conversation.

STEP 3 — Start with 10 to 15 minutes of cardiovascular exercise daily. Each week,

add five minutes to your exercise routine until you reach 30 minutes of moderate-
intensity for a minimum of five days per week. Alternately, you may do 20 minutes of
vigorous-intensity exercise three days per week. The 30-minute recommendation is for
the average healthy adult to maintain health and reduce the risk for chronic disease. It
should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of physical
activity may be necessary.

STEP 4 — Incorporate strength training into your routine. Do eight to 10 strength-

training exercises, eight to 12 repetitions of each exercise twice a week. This can be
accomplished by using dumbbells, resistance bands or your own body weight. If you are
unsure how to perform the exercises correctly, seek the advice of an exercise
professional.

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Guidelines for adults over age 65 (or adults 50-64 with chronic conditions, such as
arthritis)*

STEP 1 — Have a physical activity plan. Older adults or adults with chronic conditions
should develop an activity plan with a health care professional to manage risks and take
special needs into account. Both aerobic and muscle-strengthening activity is critical for
healthy aging.

STEP 2 — Balance and muscle-strengthening exercise may help prevent falls.

Please ask your health care professional for a referral to a clinical health and fitness
professional who can help you learn to perform these exercises safely and effectively.

STEP 3 — Follow the steps listed above. Your health care professional will modify
these steps to meet your individual needs. Both aerobic and muscle-strengthening
activity is critical for healthy aging.

RECOMMENDATIONS AND FOLLOW-UP PLAN:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

QUESTIONS OR CONCERNS?

Health Care Professional: ________________________________________________

Office Phone/E-mail: ____________________________________________________

For more information, visit www.exerciseismedicine.org.

*If your health care professional has not cleared you for independent physical activity,
you should exercise only under the supervision of a certified health and fitness
professional. The American College of Sports Medicine has two groups of certified
fitness professionals that could meet your needs. The ACSM Certified Clinical Exercise
Specialist (CES) is certified to support those with heart disease, diabetes and lung
disease. The ACSM Registered Clinical Exercise Physiologist (RCEP) is qualified to
support patients with a wide range of health challenges. You may locate all ACSM-
certified fitness professionals by using the ProFinder at www.acsm.org.

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HOW TO PRESCRIPTION EXERCISE
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GUIDE
FORM

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STARTING AN YOUR OFFICE FLIER
EXERCISE PRESCRIPTION
PROGRAM FOR HEALTH

YOUR PRESCRIPTION FOR HEALTH FLIER SERIES

Information and recommendations for

exercising safely with a variety of health conditions.

This series is available for download at

www.exerciseismedicine.org/YourPrescription.htm

www.ExerciseIsMedicine.org

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HOW TO PRESCRIPTION EXERCISE
USE THE & REFERRAL PRESCRIPTION
PROCESS & REFERRAL
GUIDE
FORM

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STARTING AN YOUR OFFICE FLIER
EXERCISE PRESCRIPTION
PROGRAM FOR HEALTH

OFFICE FLIER

Available for download in high resolution (for printing)

and low resolution (for e-mail attachments)
at www.exerciseismedicine.org/nurses.htm.

www.ExerciseIsMedicine.org

E-mail: [email protected] • Phone: 317-637-9200 9

 Nurses’ Preparticipation Screening Flowchart
Administer PAR-Q

Patient answered “Yes” to any of the PAR-Q Patient answered “No” to

questions. all of the PAR-Q
questions.

Clear for independent or Clear for independent physical activity*

monitored physical activity*

IF cleared for clinically monitored IF cleared for community-based yet IF cleared for independent physical
physical activity THEN refer to monitored physical activity THEN refer to activity (may be minimal restrictions)
clinical fitness professional1 health fitness professional with special THEN determine desire for personalized
populations related certification2 exercise support.

Pre-participation Checklist
1. Has your health care provider ever said that you have a heart condition IF patient desires IF patient desires only general IF patient desires IF patient desires only
and that you should only do physical activity recommended by a health care personalized exercise guidelines and no personalize personalized general guidelines and
provider? support THEN refer to support THEN provide with support exercise support no personalized support
2. Do you feel pain in your chest when you do physical activity? certified fitness based on Federal Physical Activity THEN refer to THEN provide with
3. In the past month, have you had chest pain when you were not doing professional3 Guidelines certified fitness support based on
physical activity? professional3 Federal Physical Activity
4. Do you lose your balance because of dizziness or do you ever lose Guidelines
consciousness?
5. Do you have a bone or joint problem that could be made worse by a
change in your physical activity? *Note: This step must be completed by a health care provider licensed to provide clinical support and medical advice (e.g., nurse practitioners). If you are not
6. Is your health care provider currently prescribing drugs (for example, licensed to provide independent clinical support, please refer your patient to the appropriate health care provider on staff.
water pills) for your blood pressure or heart condition? 1 - A clinical fitness professional is equivalent to an ACSM-certified Registered Clinical Exercise Physiologist (RCEP) or ACSM-certified Clinical Exercise
7. Do you know of any other reason why you should not do physical Specialist (CES) (Note: the CES is limited to providing services to patients with cardiovascular, pulmonary or metabolic disease challenges the RCEP does not have such limita-
activity? tions).
2 - A fitness professional with a special populations-related certification is equivalent to an ACSM-certified Health Fitness Specialist or either of the above
Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with
permission from the Canadian Society for Exercise Physiology.
certifications.
3 - A certified fitness professional is equivalent to an ACSM-certified Personal Trainer or any of the above certifications.
 PHYSICAL ACTIVITY READINESS
QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________

HEALTH CARE PROVIDER’S NAME: _______________________________________

Please read the questions below carefully, and answer each one honestly. Please check YES or NO.

 Yes  No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
 Yes  No Do you feel pain in your chest when you do physical activity?
 Yes  No In the past month, have you had chest pain when you were not doing physical activity?
 Yes  No Do you lose your balance because of dizziness or do you ever lose consciousness?
 Yes  No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
 Yes  No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
 Yes  No Do you know of any other reason why you should not do physical activity?

Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.

PHYSICAL ACTIVITY READINESS

QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________

HEALTH CARE PROVIDER’S NAME: _______________________________________

Please read the questions below carefully, and answer each one honestly. Please check YES or NO.

 Yes  No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
 Yes  No Do you feel pain in your chest when you do physical activity?
 Yes  No In the past month, have you had chest pain when you were not doing physical activity?
 Yes  No Do you lose your balance because of dizziness or do you ever lose consciousness?
 Yes  No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
 Yes  No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
 Yes  No Do you know of any other reason why you should not do physical activity?

Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.
 EXERCISE PRESCRIPTION
& REFERRAL FORM
PATIENT’S NAME: _________________________________________ DOB: _______________ DATE: ________________
HEALTH CARE PROVIDER’S NAME: ________________________________ SIGNATURE: _________________________

PHYSICAL ACTIVITY RECOMMENDATIONS REFERRAL TO HEALTH & FITNESS PROFESSIONAL

Type of physical Name:

Aerobic Strength
activity:
Phone:
Number of days
per week: Address:

Minutes per day:

Web Site:
Total minutes Follow-up Appointment Date:
per week*:
Notes:
*PHYSICAL ACTIVITY GUIDELINES
Adults aged 18-64 with no chronic conditions: Minimum of 150 minutes
of moderate physical activity a week (for example, 30 minutes per day,
five days a week) and muscle-strengthening activities on two or more
days a week (2008 Physical Activity Guidelines for Americans).
For more information, visit www.acsm.org/physicalactivity.

EXERCISE PRESCRIPTION
& REFERRAL FORM
PATIENT’S NAME: _________________________________________ DOB: _______________ DATE: ________________
HEALTH CARE PROVIDER’S NAME: ________________________________ SIGNATURE: _________________________

PHYSICAL ACTIVITY RECOMMENDATIONS REFERRAL TO HEALTH & FITNESS PROFESSIONAL

Type of physical Name:

Aerobic Strength
activity:
Phone:
Number of days
per week: Address:

Minutes per day:

Web Site:
Total minutes Follow-up Appointment Date:
per week*:
Notes:
*PHYSICAL ACTIVITY GUIDELINES
Adults aged 18-64 with no chronic conditions: Minimum of 150 minutes
of moderate physical activity a week (for example, 30 minutes per day,
five days a week) and muscle-strengthening activities on two or more
days a week (2008 Physical Activity Guidelines for Americans).
For more information, visit www.acsm.org/physicalactivity.
 Physical Activity Clearance Form
Clearance requested for:

Health care provider’s name:

Please sign the statement that reflects your wishes:

1. ____ This patient may engage in an exercise program only under clinical supervision.
2. ____ This patient may engage in an exercise program only under the supervision of a
community-based health club professional.
3. ____ This patient may engage in independent (unrestricted) moderate intensity exercise.

Restrictions:

Return form to:

Health care provider’s signature: Date:

Physical Activity Clearance Form

Clearance requested for:

Health care provider’s name:

Please sign the statement that reflects your wishes:

1. ____ This patient may engage in an exercise program only under clinical supervision.
2. ____ This patient may engage in an exercise program only under the supervision of a
community-based health club professional.
3. ____ This patient may engage in independent (unrestricted) moderate intensity exercise.

Restrictions:

Return form to:

Health care provider’s signature: Date: