Physical Activity Counseling Note

Date: [Date]
Provider: [Provider name, credentials]
Setting/Modality: [in-person / video / phone] | [individual / group]
Information Sources: [patient / caregiver / chart] (Note interpreter use or history limitations if applicable)

Subjective

Reason for counseling and goal: [Reason for counseling and patient's stated goal or concern]. [Brief direct quote if it clarifies motivation]

Baseline physical activity (vital sign): Aerobic: [# days/week] × [# minutes/day] = [calculated total minutes/week]. Strength training: [# days/week / not assessed]. Sedentary pattern: [brief description / not assessed] (Calculate weekly total from reported days and minutes; document "not assessed" for any component not discussed—do not estimate)

Preferences and barriers: [Preferred activities; barriers to activity; past successes or failures] (Include only items explicitly discussed)

Readiness and confidence: [Stage of change if stated] | Confidence: [0–10 or qualitative] (Include when relevant)

Exertional symptoms inquiry: Chest pain [denies / reports / not assessed]; Dyspnea [denies / reports / not assessed]; Dizziness/syncope [denies / reports / not assessed]; Palpitations [denies / reports / not assessed]. Relevant safety history: [pertinent cardiac, musculoskeletal, or other conditions impacting exercise safety / not assessed] (Required when initiating or escalating intensity)

Objective

Vitals: [Weight, BMI, BP, HR as relevant]

Pertinent comorbidities: [Conditions influencing the activity plan]

Recent tests/labs reviewed: [Pertinent results with dates] (Include only if reviewed this encounter)

Safety screening outcome: [Activity appropriate / Activity deferred]. Safe intensity: [light / moderate / vigorous]. Clearance: [none needed / medical clearance advised / supervised program recommended] (Required when initiating or escalating intensity)

Assessment

Current activity level vs. guidelines: [inactive / insufficiently active / meets guideline]

Key limitations: [Primary barriers, functional limits, medical constraints]

Main counseling target today: [Single most important focus for this encounter]

Risk considerations: [Brief rationale for selected intensity and precautions]

Plan

Counseling summary: Guideline targets discussed: [aerobic and strength recommendations reviewed]. Behavior change techniques: [goal-setting / action planning / problem-solving / self-monitoring / other]. Patient preferences incorporated: [how preferences shaped plan]

Exercise prescription (FITT): Frequency: [# days/week]. Intensity: [light / moderate / vigorous] via [talk test / RPE target / HR target]. Time: [minutes/session] → [weekly total]. Type: [activity type(s)]

Progression: [Specific progression plan—typically increase time first, then frequency, then intensity]

Strength training: [# days/week], [muscle groups], [sets/reps/effort level] (Include when prescribed)

Condition-specific modifications: [Relevant adaptations based on comorbidities] (Include only if applicable)

Safety precautions: Stop and seek care for: [chest pain, syncope, unusual dyspnea, concerning symptoms]. Injury prevention: [warm-up, gradual progression, appropriate footwear]

Follow-up and tracking: Interval: [timeframe]. Tracking metrics: [1–3 specific measures]. Method: [paper log / app / wearable]. Adjustment criteria: [when to increase or decrease activity]

Referrals: [Service] — [brief rationale] (Include only if placed)

(If safe intensity cannot be determined due to incomplete screening, default to light-intensity activity with conservative volume and document the reason)