Exercise is Medicine

A blueprint to work with health care providers

This Exercise is Medicine® Action Guide provides exercise professionals with a blueprint for how to work effectively with physicians and other health care providers to use exercise and physical activity, in the correct “dosage,” as an effective patient care “prescription.” This guide supports one of the primary goals of the Exercise is Medicine initiative: to bring health care providers and exercise professionals together as part of the care continuum and ensure that exercise professionals are prepared to work safely and effectively with referred patients.

The guide outlines a four-step approach to work with health care providers and patients/clients to facilitate and manage medical referrals:

Step 1: Professional Preparation
Step 2: Connect with Health Care Providers
Step 3: Work with Referred Patients
Step 4: Communicate Patient Progress

Be sure to use the guide’s sample forms and templates to optimize opportunities to build credibility and work with health care professionals in your community. Due to potential variations in the law from one state to another, these documents should be reviewed and approved by legal counsel before they are used by you/your organization. ACSM makes no warranties or representations regarding the documents provided in this guide, and you/your organization assume all risk associated with any use of these documents.

ACSM’s Exercise Preparticipation Screening Questionnaire for Exercise Professionals
- Use in conjunction with the screening algorithm from ACSM’s Guidelines for Exercise Testing and Prescription
Health History Questionnaire
Sample Medical Clearance Form
- If you are going to reproduce this form (written or electronic), please obtain permission from the author first
Fitness Assessment Data Sheet template
- Modify this template to reflect the assessments that you typically provide
Initial Fitness Assessment/Physical Activity Plan
Patient Fitness Progress Report
Informed Consent for Participation in a Health & Fitness Training Program
Cancellation Policy
ACSM’s Rx for Health series handouts

Proceed to Step 1: Professional Preparation

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Gold level recognition is the highest level of recognition and signifies the implementation of one or several components of the EIM Solution on the University campus, with the potential of extending into the local community. Community partnerships provide real world experience for students, while providing service to the local community.

Gold level campuses must assess physical activity as a vital sign.

A Gold level campus must also be engaged in at least (1) of the following:

* My campus assesses their patients' physical activity as a vital sign?

Yes No

* My campus is creating collaborations between university health care professionals and exercise professionals to provide physical activity prescriptions?

Yes No

* My campus has non-clinical professionals/departments directing students, faculty, and/or staff to the recreation center for health and fitness counseling?

Yes No

* My campus has a computer-based system to track patient participation in physical activity interventions?

Yes No

Other:

Silver level recognition includes activities related to awareness and promotion, and incorporates education for the university’s students, faculty, staff, and health care professionals, as well as those in the surrounding community, on EIM and its mission on campus. Silver campuses are actively engaged in educating others on the EIM solution for both the treatment and prevention of long-term illness and disease. University students are educated on the aims of EIM in health care, potentially certified as EIM health fitness professionals, and guided on how they can play a role in making physical activity an integral part of health care.

Silver level campuses must be engaged in at least (3) of the following: * My campus hosts classes that teach students the fundamentals of EIM on Campus and their potential role in fulfilling the mission of EIM?

Yes No

* My campus trains students to educate campus community members on EIM and the importance of physical activity as medicine?

Yes No

* My campus works with campus health services so that every health care provider discusses physical activity with every patient or client?

Yes No

Other:

Bronze level recognition is the first step in creating the EIM initiative on Campus. These campuses bring attention to the growing need for physical activity and take action in helping to create a healthier, more active campus environment.

Bronze level campuses create awareness of the importance of exercise and regular physical activity for health and promote exercise to students, faculty, staff and the community through engagement in any of the following activities. Bronze level campuses must engage in at least (3) of the following:

* My campus hosts events that promote physical activity?

Yes No

* My campus markets events that encourage all campus members to discuss physical activity with their health care professional?

Yes No

* My campus has created options for exercise that are easily accessible to the campus community?

Yes No

* My campus has completed a Mayoral, Governor, or University President EIM on Campus Month Proclamation?

Yes No

Other:

* Contact Person/Program Director:

* Resource Type (check all that apply):
Clinic or Hospital (inpatient) Community
Clinic or Hospital (outpatient) Home Based
Cancer Exercise Professional Digital/Online
Research Study

* What age groups are included (check all that apply)?
Adult Pediatric

* What cancer types are included in your program?

* What stages of treatment are included (check all that apply)?
Curative    Palliative
During Treatment    Post Treatment
Rehabilitation    Prehabilitation

* Who refers into the program? (How do clients access your program?) (check all that apply)
Client Clinician
Other

* What are the qualifications of the instructors?

* Is there a baseline safety evaluation of the client?

* If yes, performed by whom (check all that apply)?
Instructor Physician
Other

* What is the program duration? (e.g.; 12 weeks, 1 year)

* What is the frequency of sessions per week?

* Are sessions conducted in groups or individualized (check all that apply)?
Group Individualized

* How many years has the program been running?

* How many clients go through your program per year?

* Has your program ever been evaluated or audited?

* Please include a brief description (250 words or less) summarizing the above information:

* Who filled out this form?

* What is your role in the program?

The guide outlines a four-step approach to work with health care providers and patients/clients to facilitate and manage medical referrals:

Step 1: Professional Preparation
Step 2: Connect with Health Care Providers
Step 3: Work with Referred Patients
Step 4: Communicate Patient Progress

ACSM’s Exercise Preparticipation Screening Questionnaire for Exercise Professionals
- Use in conjunction with the screening algorithm from ACSM’s Guidelines for Exercise Testing and Prescription
Health History Questionnaire
Sample Medical Clearance Form
- If you are going to reproduce this form (written or electronic), please obtain permission from the author first
Fitness Assessment Data Sheet template
- Modify this template to reflect the assessments that you typically provide
Initial Fitness Assessment/Physical Activity Plan
Patient Fitness Progress Report
Informed Consent for Participation in a Health & Fitness Training Program
Cancellation Policy
ACSM’s Rx for Health series handouts

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Exercise Pros Action Guide

A blueprint to work with health care providers

Proceed to Step 1: Professional Preparation

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