A home exercise programme template patients and families can follow, with sample entries showing plain, specific instructions.
✓Written for patients, not clinicians
✓Stop-and-call list you edit
✓Weekly log on the same sheet
Free · No sign-up · Saves in your browser
What's inside
Your Goals
Exercises
How Much Discomfort Is Okay
Stop and Contact the Clinic If
Precautions
Weekly Log
Who Helps at Home
Questions for Your Next Visit
Preview · 8 sections
Physiotherapy Home Exercise Programme
Patient
Date given
Physiotherapist
Review date
Clinic phone
Language of instructions
Your Goals
What these exercises are forOne or two lines in the patient's own words.
Exercises
#
Exercise (picture or video reference)
How to Do It
Sets × Reps / Hold
How Often
Equipment
1
2
3
4
5
How Much Discomfort Is Okay
Discomfort limitsThe limits the physiotherapist has agreed with this patient, on the same pain scale used in clinic.
Stop and Contact the Clinic If
☐ Pain is much worse and does not settle with rest
☐ New numbness, tingling or weakness
☐ New swelling, redness or heat
☐ You feel dizzy, breathless or unwell
☐ You have a fall
Precautions
Precautions for homeMovements to avoid and until when, with their source.
Weekly Log
Day
Morning Done?
Evening Done?
Pain or Effort
Comments
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Who Helps at Home
Family member or attendant helpingName, relation, and what they should do: count, steady, remind.
Questions for Your Next Visit
Questions for your next visit
How to fill it in
1
Your Goals
One or two lines, in the patient's words, on what the exercises are for.
More guidance
One or two lines, in the patient's words, on what the exercises are for. People keep doing exercises they can connect to something they want, such as walking to the temple, lifting a grandchild or riding to work. Leave anatomy out of this section.
2
Exercises
Each exercise's plain name, how to do it, the amount, how often, and equipment.
More guidance
Give each exercise a plain name and a short instruction: the starting position, the movement, and what the patient should feel. Then the amount (sets and repetitions, or hold time), how often in a day, and any equipment, such as a rolled towel or a chair of stated height. Add a picture reference, or note that a video was recorded on the patient's phone. A short list that fits the patient's day is more likely to be done than a long one.
3
How Much Discomfort Is Okay
The discomfort limits you agreed, on the same pain scale used in clinic.
More guidance
Write the limits you have agreed with this patient in words they will remember: what discomfort is acceptable during and after the exercises, and how long it may last. Use the same pain scale you use in clinic so the patient can report back in the same terms. Many patients decide whether to stop based on this section alone, so be clear.
4
Stop and Contact the Clinic If
Warning signs for this patient that mean stop and call, and who to call.
More guidance
List the warning signs that mean this patient should stop and call, written for their situation. The checklist in the template is a starting point for you to edit, not a clinical rule set. Put the clinic's phone number in the details table and say who to call outside clinic hours, if your clinic has an arrangement for that.
5
Precautions
Confirmed precautions as plain do and don't statements, with dates and their source.
More guidance
Record the precautions the treating physiotherapist has confirmed, such as movements to avoid after surgery and until when. Write them as plain do and don't statements with dates. If they come from the surgeon's instructions, say so, so the family understands why they matter.
6
Weekly Log
Morning and evening ticks, a pain or effort number, and a short comment.
More guidance
A tick for morning and evening, a number for pain or effort, and a short comment. The log turns 'I do them mostly' into something you can discuss. Ask the patient to bring the sheet, or send a photo of it, before each visit, and look at it with them at the start of the session.
7
Who Helps at Home
The helper's name, their relation, and what they should do: count, steady, remind.
More guidance
Name the person who will help or supervise, their relation, and what you want them to do: count, steady the chair, remind. In joint families the person helping at home is often not the person who came to clinic, so make sure the sheet explains enough for someone who never met you.
8
Questions for Your Next Visit
Space for questions that come up during the week.
More guidance
Leave space for questions as they come up during the week. Patients forget them by the time they reach the clinic, and the questions often show where an exercise was misunderstood.
Home exercise programme template and sample sheet: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Your Goals
To climb the stairs to my flat without stopping, and to sit on the floor for meals again.
Exercises
1. Sit to stand. Sit on the dining chair without arms, feet flat, arms crossed. Lean forward, stand up fully, then sit down slowly. 2 sets of 8, morning and evening. You should feel your thighs working.
How Much Discomfort Is Okay
Some aching during the exercises is expected and should settle within an hour. If pain goes above the number we agreed (5 on your 0 to 10 scale), or is worse the next morning, do fewer repetitions and tell us at your next visit.
Precautions
Do not kneel on your left knee until your review on 15 November (surgeon's instruction). Use the rail on the stairs every time.
Weekly Log
Wed: morning yes, evening no. Pain 3. 'Too tired after night shift.'
Who Helps at Home
Granddaughter A., 16, holds the chair steady and counts repetitions for the evening set.
Written HEP sheet or exercise video on WhatsApp?
Written HEP sheet
Exercise video on the patient's phone
Shows the movement
Through words and pictures only
Clearly, and in the patient's own home if recorded there
Shows the amount and limits
Sets, repetitions, frequency and precautions in one place
Often missing unless you say them aloud while recording
Easy to find later
On the fridge door or in the file
Easily lost among family messages
Records what was done
Weekly log on the same sheet
Nothing is recorded
Best use
The reference for what to do and how much
A companion to the sheet, recorded on the patient's own phone with their consent
Tips and mistakes to avoid
Do
Teach every exercise and watch the patient do it back before you write it down.
Write in the household's language, or have a family member add a translation while you check it.
Fit exercises to the home: a dining chair of known height, the stairs, a dupatta instead of a strap.
Link exercises to an existing routine, such as after morning tea, rather than to clock times.
Reprint the sheet whenever the programme changes; two versions on the fridge lead to doubled exercises.
Avoid
Giving more exercises than the patient can realistically fit into their day.
Writing 'quads strengthening 3 × 10' with no description a family member could follow.
Leaving out when to stop, so patients either push through warning signs or give up at normal soreness.
Never asking to see the log, which tells the patient it does not matter.
Handing out a generic printed sheet with the irrelevant exercises crossed out.
About this home programme
A home exercise programme (HEP) sheet tells a patient exactly which exercises to do between sessions: what each one is, how to do it, sets and repetitions or hold times, how often, and when to stop. This free template adds precautions, a weekly log and space for the family member who helps. Fill it in online and print a PDF.
At the end of a session, after teach-back
Whenever you progress or change the programme
Home-care patients supervised by family between visits
At discharge, as the maintenance programme
Read more
Most physiotherapy happens at home. A patient seen twice a week spends the rest of the week deciding whether to exercise, so the HEP sheet carries much of the work.
Write it for the patient and whoever helps them, in plain words and the language the household reads. The physiotherapist fills in every exercise, amount and precaution; the template suggests none.
Questions
What should a home exercise programme include?+
The patient's goals, numbered exercises with plain instructions, the amount and frequency of each, agreed discomfort limits, warning signs that mean stop and call, confirmed precautions, a weekly log, and who helps at home. This template has a section for each.
Is there a filled sample of this HEP sheet?+
Yes. Most sections in the guide above show a fictional sample entry, initials only. The stop-and-call list has no sample, because you edit it for each patient. Samples show wording; every exercise and amount is the physiotherapist's choice.
Is this the same as a home exercise program (HEP) template?+
Yes. 'Programme' is the UK and Indian spelling and 'program' the US one; the document is the same. Many clinicians simply call it the HEP sheet.
How many exercises should a home programme have?+
As many as the patient will actually do, which the treating physiotherapist judges. A short programme done daily usually beats a long one done now and then. Review and trim it at each visit.
Can I add pictures to the HEP sheet?+
Yes. Each exercise row has a column for a picture or video reference. Add your clinic's illustrations, sketch on the printout, or note that a video was recorded on the patient's phone.
Should I send the HEP over WhatsApp?+
Many families prefer it. Send the PDF with the patient's consent and within your privacy policy, and still hand a printed copy to older patients who may not open attachments.
Can the patient track pain as well?+
The weekly log has a column for pain or effort. For more detail, pair the HEP with the pain and exercise diary, which records pain before and after exercise each day.
