EngAge Wellness Program - Exercise is Medicine™ Prescription & Referral Form

Health care provider instructions for EngAge Wellness "Exercise is Medicine™" 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 "Exercise is Medicine™" program (minimum age 50 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:
Patient's Address:
Patient's Phone Number:
Reason for referral:
Wt. loss BP Diabetes Balance Arthritis Bone health Cardiovascular endurance Muscular strength Overall health
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: 04/21/2018

EngAge Wellness "Exercise is Medicine™" program includes:

  1. FREE two week participation in the EngAge Wellness program.
  2. Functional fitness assessment (Senior Fitness Test).
  3. Balance assessment (FAB4)
  4. Individualized fitness program designed by a degreed exercise science professional.
  5. One-on-one orientation to patient's fitness program.
  6. Option to participate in group movement classes (T'ai Chi, toning, low impact aerobics, stretching, etc.)
  7. Referral to other appropriate services to reach patient wellness goals.
  8. Communication back to health care provider regarding patient's participation and progress.

Type the text from the image into the space below.

Form last updated 04/3/18

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