EXERCISE PRESCRIPTION WORKSHEET

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					                                     EXERCISE PRESCRIPTION WORKSHEET

    Date      Rx Method        ETT Results       Suggested Rx          Beta Blocker   Selected Rx %    Target Range

                No ETT              Not         Rest + (20-30 beats)
                                  Available

                                  < 5 METS      Rest + (20-30 beats)     yes   no

               Heart Rate
                                  > 5 METS          60 - 80%             yes   no
                                                Karvonen Formula

                                  < 5 METS         40 - 60% FC           yes   no
               Functional
                Capacity
                                  > 5 METS         60 - 70% FC           yes   no



Rx Rest HR: __________          If different from ETT, state reason: ______________________________________________

Rx Max HR: __________           If different from ETT, state reason: ______________________________________________

                            Other Information
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