Get Renal Services Exercise Prescription Form - University Of Virginia ... - Healthsystem Virginia

Filling out the Renal Services Exercise Prescription Form is a crucial step in managing your health and tailoring an exercise program to meet your unique needs. This guide will provide you with detailed, step-by-step instructions on how to accurately complete the form online.

Follow the steps to effectively complete the exercise prescription form.

1. Click ‘Get Form’ button to access the Renal Services Exercise Prescription Form and open it for editing.
2. Begin by entering your name in the designated field at the top of the form. Ensure that the spelling is accurate to avoid any discrepancies.
3. Fill in the name of your attending physician. This information is important for healthcare coordination.
4. Provide the date on which you are completing the form. This helps document the timeline of your exercise prescription.
5. Indicate the facility where you are receiving care. This information is useful for healthcare providers.
6. Enter your ID number and medical record number (MR#). This information is crucial for patient identification within the healthcare system.
7. Fill in your date of birth to confirm your identity and age-related needs.
8. Specify your gender and age in the respective fields, as this data may influence exercise recommendations.
9. Detail the cause of end-stage renal disease (ESRD) and any relevant medical history in the medical history section. Be thorough for accurate prescription tailoring.
10. Indicate any access devices that may be relevant to your condition.
11. In the exercise prescription section, specify your activity level prior to the exercise program. This will guide your healthcare provider in making appropriate recommendations.
12. Enter the ICD9 code for exercise, if applicable. This code helps align your exercise prescription with medical billing and records.
13. Document the duration and type of warm-up exercises you plan to perform.
14. In the cardiovascular exercise section, indicate the mode, intensity, rating of perceived exertion (RPE), frequency, and duration according to your comfort and physical capabilities.
15. Specify cool-down activities similar to the warm-up, including duration and type.
16. Detail your weight training program or any home program exercises, including their frequency and duration.
17. Provide information on any exercise tests conducted, including date, type, test time, weight (in kg and lbs), and pre- and post-exercise heart rates and blood pressure readings.
18. Include any comments relevant to your exercise program or health status.
19. Indicate whether a follow-up is necessary. Check yes or no, and specify the type if applicable.
20. In the section for other considerations, document any additional information pertinent to your exercise prescription.
21. Lastly, the exercise physiologist should sign and date the form to validate the exercise prescription.
22. After completing all sections of the form, review your entries for accuracy, save your changes, and use the options to download, print, or share the form as needed.

Complete your Renal Services Exercise Prescription Form online today to take an important step towards managing your health.