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Home Exercise Program Log template

A free home exercise program log patients fill out from their phone each day. Track adherence, pain before and after, and difficulty so you can adjust the program between visits.

Home Exercise Program Log

Fill this out each day you do your home exercises. It takes under a minute, and it helps your therapist adjust your program between visits.

Your name *

Date *

Did you do your exercises today? *

Which exercises did you skip, and why? *

What got in the way today? *

How many sets did you complete?

Pain before exercising (0 = none, 10 = worst) *

Pain after exercising (0 = none, 10 = worst) *

How did the exercises feel? *

Notes or questions for your therapist

What to track in a home exercise log

  1. Did they do it today
  2. What got in the way
  3. Sets completed
  4. Pain before exercise
  5. Pain after exercise
  6. How hard it felt
  7. Questions for the therapist
What's included
  • Your name
  • Date
  • Did you do your exercises today?
  • Which exercises did you skip, and why?
  • What got in the way today?
  • How many sets did you complete?
  • Pain before exercising (0 = none, 10 = worst)
  • Pain after exercising (0 = none, 10 = worst)
  • How did the exercises feel?
  • Notes or questions for your therapist
Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.