Does your patient currently have symptoms of angina that would limit participation in physical activity (such as chest pain or severe pressure on physical exertion)?Yes No
Patient should be referred for further medical evaluation as soon as possible
Continue to Part 2 to assess your patient's physical activity level and participation
Please complete step 1
In a typical week, how many days per week and minutes per day does your patient consistently do moderate intensity aerobic physical activity (such as a brisk walk) to vigorous intensity (such as jogging)?days per week (range 0-7)
How many days in a week does your patient complete resistance training?days per week (range 0-7) Submit
Would your patient like to become more active or try a new activity?Yes No
Advise patient of benefits of reducing sedentary behaviour for diabetes management
Advise patient of benefits of resistance activities for diabetes management
Acknowledge barriers, identify potential sources of motivation and recommend the brochure: Benefits of Physical Activity
Please complete step 2
Moving forward, what level (intensity) and type (aerobic and/or resistance) of physical activity or exercise would your patient like to do?
*IMPORTANT* Does your patient have any musculo-skeletal injuries or medical limitations that limits their ability to do physical activity (aerobic) and / or exercise (resistance)?Yes No
Has your patient had a previous coronary event, MI or stroke? Or, do they have complications from diabetes such as severe retinopathy, nephropathy or, advanced neuropathy? Is your patient at high risk for cardiovascular event? I.e. have they had a previous coronary event, MI, stroke? Or do they have severe diabetic complications such as severe retinopathy, nephropathy or advanced neuropathy?Yes No
*CAUTION*: Patients with pre-proliferative or proliferative retinopathy should be treated and stabilized prior to starting vigorous exercise. Patients with severe peripheral neuropathy should wear appropriate footwear and inspect their feet daily, especially on days they are physically active.
Does your patient have availability (location) and resources (monetary) to access a program or facility for resistance exercise or are there resources to seek out the advice of a Qualified Exercise Professional (QEP)?Yes No
Which type of resistance exercise is more appealing to your patient?Resistance bands Dumbbells / body exercises
Add MVPA score to the patient care flow sheet or medical record
If anyone experiences severe pressure in the chest, severe shortness of breath, or severe leg pain that stops physical activity or, gets worse with the progression of activity, a referral for medical evaluation is strongly recommended.
Signs and symptoms of peripheral artery disease: Pain in either leg on walking, typically in calf (or calves) that causes you stop or slow down, and typically disappears in 10 minutes or less.
** For those with mild to moderate arthritis, increasing physical activity may benefit symptoms. Options for physical activity that may be more comfortable are water based activities, pool walking, recumbent cycling or stepping and mild resistance training (such as resistance bands). Referral to a qualified exercise professional is recommended to help create or modify a suitable exercise routine.
|Max HR||Maximum Heart Rate|
|RPE||Rate of Perceived Exertion|
|MVPA||Moderate to Vigorous Physical Activity|