Home Exercise & Self-Care Program Instructions

Home Exercise Program Instructions

Patient: [patient name or first name + last initial per local policy]
Date Given: [date]
Clinician: [clinician name, credentials, clinic name]
Contact: [clinic phone - INSERT required]
Hours: [clinic hours - INSERT required]
After-hours instructions: [how to reach on-call or where to seek care after hours - INSERT required]

Your Plan at a Glance

Main goal: [one clear sentence describing the main goal or focus]

• [Do the exercises below [daily / every other day / ___ times per week]]
• [Use [heat / ice] as directed below] (Only include if prescribed)
• [Avoid the activities listed below for now] (Only include if discussed)
• [Contact us if you have any warning symptoms listed in Safety]
• [Approximate time per day: [total minutes]] (Only include if specified)

Your Home Exercises

When to do your exercises: [timing such as morning, evening, or tied to a daily habit]
What discomfort is ok: Mild discomfort or stretch is normal. Sharp pain, new numbness, or symptoms that do not settle means stop.
Equipment needed: [list items] (Omit line if none)

(Add one row per exercise. Do not list any exercise without explicit dosage. Remove Video/Image column if no links are provided.)

(Duplicate row for each exercise prescribed.)

Exercise name	Purpose	How to do it	Dosage	When to stop or modify	Video or image
[exercise name in patient-friendly words]	[mobility / flexibility / strength / balance / posture / breathing]	[key cue 1] [key cue 2] [key cue 3] (Omit if not needed)	[sets × reps, hold time, frequency] (Must be explicit; if pending write "Dosage to be confirmed at next visit")	[stop or modify rule for this exercise]	[link or reference] (Omit column if none)

Progression: [rule for making it harder, e.g., "When this feels easy, work up to 3 sets of 12"] (Include only if planned)
If you need to make it easier: [rule for reducing load, e.g., "If pain increases, reduce reps or add a rest break"] (Include only if discussed)

Optional tracking (Omit table if not used):

(Add rows for each exercise as needed.)

Exercise	Mon	Tue	Wed	Thu	Fri	Sat	Sun
[exercise name]

Activity and Self-Care

(Include only items explicitly advised. Omit any subsection not discussed.)

Do more of:

• [specific activities to increase, such as short walks, gentle movement, posture breaks]
• [ergonomic or sleep positioning tips] (Only include if addressed)

Avoid for now:

• [specific activities or positions to limit or avoid]

Heat or ice (Include only if prescribed):

• Use [heat / ice]
• When: [after exercise / when symptoms flare / other timing]
• Duration: [10–20 minutes per session]
• Always place a towel between skin and pack
• Maximum: [frequency per day]

Other self-care (Include only if advised):

• [elevation / compression / breathing exercises / pacing strategy]

Safety: When to Stop and When to Seek Help

Stop and rest during exercise if you have:

• Dizziness or lightheadedness
• Chest pain, pressure, or unusual shortness of breath
• New or worsening weakness
• Numbness or tingling that spreads or does not settle
• Feeling unstable or at risk of falling

Call 911 or go to the emergency room now if you have:

• [diagnosis-appropriate emergency red flags from organization-approved list] (Select only items relevant to this condition. Common MSK/spine examples: sudden loss of bowel or bladder control; numbness in the groin or saddle area; rapidly worsening leg weakness; chest pain with other heart symptoms; signs of stroke.)

Call the clinic or seek urgent care within 24 hours if you have:

• [condition-relevant urgent symptoms from organization-approved list] (Examples: fever with increasing redness or swelling; new significant swelling or calf pain; wound concerns after a procedure; severe pain not improving with rest.)

Follow-Up

Next visit: [date and time] (If not yet scheduled, write: "Call to schedule within [timeframe]")
Questions? Call us at [clinic phone - INSERT required]

Tips to stay on track (Choose one or two):

• Tie exercises to a daily routine, like after brushing your teeth
• Set a phone reminder or calendar alert
• Keep equipment where you will see it

Your notes or questions for next visit:

[space for patient to write]