Health care provider instructions for Engage Wellness "Engage in Exercise" program:

1. Assess patient's exercise habits as a vital sign at each patient visit and encourage patient to be physically active.
2. Refer appropriate patients to Engage Wellness "Engage in Exercise" program (minimum age 19 years).
3. Complete form and fax to 402-552-7209. Patient will be contacted to schedule an appointment.
4. You will receive communication regarding patient's participation and progress.

Patient's Name:

DOB:

Patient's Address:

City:

State:

Zip:

Patient's Phone Number:

Email:

Reason for referral:

Wt. loss BP Diabetes Balance Arthritis Bone health Cardiovascular endurance Muscular strength Overall health FallProof™ Fit & Strong! Arthritis Program Diabetes Prevention Program

Other:

Patient may engage in fitness assessment(s) (including cardiovascular endurance, muscular strength & endurance, upper & lower body flexibility, balance & gait), group movement classes, and an individualized exercise program designed by an exercise professional.

Assessment and/or exercise restrictions (if any):

Patient may participate in an onsite weight management or other nutritional counseling program if they choose.

Nutrition Restrictions (if any):

Health Care Provider's Name:

License Number:

Date: 05/15/2024

Practice:

Phone:

Fax:

Engage Wellness "Engage in Exercise" program includes:

1. One-month trial of participation in the Engage Wellness program, for a fee.
2. Functional fitness & balance assessment.
3. Individualized fitness program designed by a degreed exercise science professional.
4. One-on-one orientation to patient’s fitness program.
5. Option to participate in group movement classes (Tai Chi, Toning, Stretching, Line Dancing, Cardio Box, & Step) - currently offered Virtually via Facebook.
6. Referral to other appropriate services to reach patient wellness goals.
7. Communication back to health care provider regarding patient’s participation and progress.