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PHYSICAL THERAPY Skills

Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.

* * *

*Indicates Required Fields

	PROFICIENCY	FREQUENCY
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KEY
Proficiency : [1] None [2] Intermittent [3] Experienced [4] Supervise / Teach
Frequency : [1] Never / Observation only [2] Less Than 6 Months [3] Twice / Month [4] Daily - Weekly
Adult/Geriatric
Neck/ Back Syndromes/Surgeries	1 2 3 4	1 2 3 4
Hip Fractures	1 2 3 4	1 2 3 4
Total Joint Replacement/UE	1 2 3 4	1 2 3 4
Total Hip/Knee Replacement	1 2 3 4	1 2 3 4
Hand Injuries	1 2 3 4	1 2 3 4
TMJ	1 2 3 4	1 2 3 4
Arthritis Programs	1 2 3 4	1 2 3 4
Amputations	1 2 3 4	1 2 3 4
Osteoporosis	1 2 3 4	1 2 3 4
Degenerative Joint/Disk Disease	1 2 3 4	1 2 3 4
Neurologic
Stroke Rehab	1 2 3 4	1 2 3 4
Head Trauma	1 2 3 4	1 2 3 4
Spinal Cord Injury	1 2 3 4	1 2 3 4
Traumatic Brain Injury	1 2 3 4	1 2 3 4
Splinting	1 2 3 4	1 2 3 4
Adaptive Equipment	1 2 3 4	1 2 3 4
Peripheral Nerve Injury	1 2 3 4	1 2 3 4
Muscle Spasms/Spasiticity	1 2 3 4	1 2 3 4
Parkinson's	1 2 3 4	1 2 3 4
Alzheimer's/Dementia/Cognitive Disorders	1 2 3 4	1 2 3 4
Cardiopulmonary/Circulatory
Cardiac Rehab	1 2 3 4	1 2 3 4
Myocardial Infarction	1 2 3 4	1 2 3 4
Congestive Heart Failure	1 2 3 4	1 2 3 4
Emphysema	1 2 3 4	1 2 3 4
COPD	1 2 3 4	1 2 3 4
Lymphedema	1 2 3 4	1 2 3 4
Peripheral Vascular Disease	1 2 3 4	1 2 3 4
Sports Medicine
Athletic Injuries	1 2 3 4	1 2 3 4
Recreational Trauma	1 2 3 4	1 2 3 4
Biodex	1 2 3 4	1 2 3 4
Cybex	1 2 3 4	1 2 3 4
Orthotron	1 2 3 4	1 2 3 4
Taping	1 2 3 4	1 2 3 4
Lido	1 2 3 4	1 2 3 4
Nautilus/Eagle	1 2 3 4	1 2 3 4
Work Place Injury
Work Hardening	1 2 3 4	1 2 3 4
Work Capacity Evaluation	1 2 3 4	1 2 3 4
Functional Capacity Evaluation	1 2 3 4	1 2 3 4
Ergonomics	1 2 3 4	1 2 3 4
Carpal Tunnel Syndrome	1 2 3 4	1 2 3 4
Cumulative Trauma	1 2 3 4	1 2 3 4
Stress Disorders	1 2 3 4	1 2 3 4
Prosthetic/Orthotic
AK Prosthetic	1 2 3 4	1 2 3 4
BK Prosthetic	1 2 3 4	1 2 3 4
HF Prosthetic	1 2 3 4	1 2 3 4
Ankle/Foot Prosthetic	1 2 3 4	1 2 3 4
Splints (wrist/hand)	1 2 3 4	1 2 3 4
UE Splinting	1 2 3 4	1 2 3 4
Static	1 2 3 4	1 2 3 4
Dynamic	1 2 3 4	1 2 3 4
Orthotic Prescription	1 2 3 4	1 2 3 4
Modalities/Procedures
Mobilization	1 2 3 4	1 2 3 4
Spinal Extremity	1 2 3 4	1 2 3 4
MFR	1 2 3 4	1 2 3 4
Craniosacral Techniques	1 2 3 4	1 2 3 4
Continuous Passive Motion Machines	1 2 3 4	1 2 3 4
Hydrotherapy	1 2 3 4	1 2 3 4
Whirlpool	1 2 3 4	1 2 3 4
Hubbard Tank	1 2 3 4	1 2 3 4
Swimex/Therapeutic Pool	1 2 3 4	1 2 3 4
Traction	1 2 3 4	1 2 3 4
Cervical	1 2 3 4	1 2 3 4
Lumbar	1 2 3 4	1 2 3 4
Massage	1 2 3 4	1 2 3 4
Ultrasound	1 2 3 4	1 2 3 4
Tens	1 2 3 4	1 2 3 4
Biofeedback	1 2 3 4	1 2 3 4
Diathermy	1 2 3 4	1 2 3 4
E-Stim	1 2 3 4	1 2 3 4
Accupressure	1 2 3 4	1 2 3 4
Other
Wound Care/Management	1 2 3 4	1 2 3 4
Burn Care/Management	1 2 3 4	1 2 3 4
Chest Fit	1 2 3 4	1 2 3 4
Cancer	1 2 3 4	1 2 3 4
AIDS/HIV	1 2 3 4	1 2 3 4
Isolation Precautions	1 2 3 4	1 2 3 4
ICU/CCU/SICU Procedures	1 2 3 4	1 2 3 4
SNF Documentation	1 2 3 4	1 2 3 4
700 Series	1 2 3 4	1 2 3 4
PPS	1 2 3 4	1 2 3 4
Medicare A	1 2 3 4	1 2 3 4
Medicare B	1 2 3 4	1 2 3 4
Medicaid	1 2 3 4	1 2 3 4
Managed Care	1 2 3 4	1 2 3 4
CQI	1 2 3 4	1 2 3 4
Management	1 2 3 4	1 2 3 4
Pediatrics
Orthopedic
Fractures	1 2 3 4	1 2 3 4
Birth Defects	1 2 3 4	1 2 3 4
Crutch/Cane Training	1 2 3 4	1 2 3 4
Neurologic
DDST	1 2 3 4	1 2 3 4
NDT	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Spinal Cord Injury	1 2 3 4	1 2 3 4
Spasticity Management	1 2 3 4	1 2 3 4
Modalities
CPM	1 2 3 4	1 2 3 4
Hydrotherapy	1 2 3 4	1 2 3 4
Prosthetics/Orthotics
Bracing	1 2 3 4	1 2 3 4
Splinting	1 2 3 4	1 2 3 4
Prosthetics	1 2 3 4	1 2 3 4
Orthotics	1 2 3 4	1 2 3 4
Experience in the Following Settings
General Acute Care Hospital	1 2 3 4	1 2 3 4
Pediatric Hospital or Clinic	1 2 3 4	1 2 3 4
Rehabilitation Hospital	1 2 3 4	1 2 3 4
Home Health	1 2 3 4	1 2 3 4
SNF	1 2 3 4	1 2 3 4
Long Term Care Facility
Private Practice	1 2 3 4	1 2 3 4
Outpatient Orthopedic Clinic	1 2 3 4	1 2 3 4
Hospice Program	1 2 3 4	1 2 3 4
Corporate/Industrial Medical Center	1 2 3 4	1 2 3 4
Work/Occupational Health	1 2 3 4	1 2 3 4
Physician's Office	1 2 3 4	1 2 3 4
Fitness Center	1 2 3 4	1 2 3 4
Sports Injury Center	1 2 3 4	1 2 3 4
Academic Research Center	1 2 3 4	1 2 3 4
Pre-School System	1 2 3 4	1 2 3 4
Primary School System	1 2 3 4	1 2 3 4
Secondary School System	1 2 3 4	1 2 3 4
Vocational Rehab	1 2 3 4	1 2 3 4
Case Management Department	1 2 3 4	1 2 3 4
Clinical Instructor	1 2 3 4	1 2 3 4
Inservice Education	1 2 3 4	1 2 3 4
Age group Settings
New Born	1 2 3 4	1 2 3 4
0-3 Years	1 2 3 4	1 2 3 4
3-5 Years	1 2 3 4	1 2 3 4
5-12 Years	1 2 3 4	1 2 3 4
12-18 Years	1 2 3 4	1 2 3 4
Adult	1 2 3 4	1 2 3 4
Geriatric	1 2 3 4	1 2 3 4
By affixing the last 4 digit of the SSN, I certify that I have electronically completed this skills checklist on the date shown below.
Last 4 digit of SSN	Date

INSTANT APPLICATION

PHYSICAL THERAPY Skills

KEY

PROFICIENCY

FREQUENCY