Modified Activity Form


NCHS Physical Education Modified Activity Form



Thank you for your recent communication regarding your patient, _______________________. Our mission as physical education instructors is to improve the fitness levels of our students especially when one considers the rise of childhood obesity.  As the above named student is under your care and currently has restrictions from Physical Education class, we would like to work with you as we develop activities that are modified to fit his/her condition.  Could you please check the activities that the student will be able to participate in during your care.  Thank you. 

Treadmill                                                                                 Elliptical


Recumbent Bike (seat with a back)                                        Core work (stability ball)


Upper body                                                                             Lower body


Swimming                                                                               Shallow water workout in pool


Physical Therapy exercises (provided by MD/PT)





            Physician’s Signature                                                     Date



Again, thank you for your cooperation in keeping our students active during your care.


NCHS Physical Education Staff