Physical Therapy Skills Checklist Form

This profile is for use by Physical Therapists with more than one year of experience in their discipline and specialty. It will not be a determining factor for the program. Return this checklist to us by mail or fax it toll free to 260-442-8884.

First Name *

Last Name *

Social Security number (Optional)

Please mark your level of experience
A - Theory, no practice
B - Intermittent experience
C - One - two years experience
D - Two plus years experience

A. Orthopedic

1. Arthritis programs

A

B

C

D

2. Back syndromes

A

B

C

D

3. Hand injury

A

B

C

D

4. Hip fractures

A

B

C

D

5. Mobilization techniques

A

B

C

D

6. Neck injuries

A

B

C

D

7. Total hip/knee replacement

A

B

C

D

8. Total joint replacement/upper extremities

A

B

C

D

9. Transmandibular joint dysfunction

A

B

C

D

B. Neurologic

1. Head trauma

A

B

C

D

2. Neurosurgery

A

B

C

D

3. Spinal cord injury

A

B

C

D

4. Stroke rehabilitation

A

B

C

D

4 a. Adaptive equipment

A

B

C

D

4 b. Functional splinting

A

B

C

D

C. Sports Medicine

1. Biodex

A

B

C

D

2. Bracing/joint immobilization

A

B

C

D

3. Cybex

A

B

C

D

4. LIDO

A

B

C

D

5. Nautilus/Eagle

A

B

C

D

6. Orthotron

A

B

C

D

7. Strength and endurance training

A

B

C

D

8. Taping/strapping

A

B

C

D

D.Modalities/Manual Skills

1. Acuscope

A

B

C

D

2. Biofeedback

A

B

C

D

3. Continuous passive motion machine

A

B

C

D

4. Craniosacral therapy

A

B

C

D

5. Cryotherapy

A

B

C

D

6. Diathermy

A

B

C

D

7. Electro-acupunture

A

B

C

D

8. Extremity mobilization

A

B

C

D

9. Fluidotherapy

A

B

C

D

a. Hubbard tank

A

B

C

D

b. Therapeutic pool

A

B

C

D

c. Whirlpool

A

B

C

D

12. Massage

A

B

C

D

13. Muscle energy techniques

A

B

C

D

14. Muscle stimulation

A

B

C

D

15. Myofascial release techniques

A

B

C

D

16. Neuro probe

A

B

C

D

17. Paraffin

A

B

C

D

18. Spinal mobilization

A

B

C

D

19. Strain/counter strain techniques

A

B

C

D

20. TENS

A

B

C

D

21. Therapeutic exercise/home programs

A

B

C

D

a. Cervical

A

B

C

D

b. Lumbar

A

B

C

D

23. Ultrasound

A

B

C

D

24. Vasopneumatic devices

A

B

C

D

25. Wound dressing

A

B

C

D

E. Prosthetics/Orthotics

1. Above knee prosthetics

A

B

C

D

2. Ankle foot orthosis

A

B

C

D

3. Below knee prosthetics

A

B

C

D

4. Dynamic splints

A

B

C

D

5. Gait analysis

A

B

C

D

6. Orthoplast/aquaplast

A

B

C

D

7. Resting splints

A

B

C

D

8. Serial/inhibitory casting

A

B

C

D

9. Static splints

A

B

C

D

10. Upper extremity prosthetics

A

B

C

D

F. Pediatrics

1. Cerebral palsy

A

B

C

D

2. Early intervention

A

B

C

D

3. Equipment assessment

A

B

C

D

a. Activities of daily living

A

B

C

D

b. Adaptive

A

B

C

D

4. Gross motor assessment tools

A

B

C

D

5. Learning disabled

A

B

C

D

6. Mental retardation

A

B

C

D

7. Neurodevelopmental treatment

A

B

C

D

8. Orthotics

A

B

C

D

9. Spina bifida

A

B

C

D

G. Computerized Testing

1. Fatigue-characteristics

A

B

C

D

2. Fiber-type

A

B

C

D

3. Functional strength

A

B

C

D

4. Net muscular torque

A

B

C

D

5. ROM

A

B

C

D

6. Work-capacity

A

B

C

D

H.Other

1. Burn management

A

B

C

D

2. Cardiac rehabilitation

A

B

C

D

3. Chest physiotherapy

A

B

C

D

4. Computerized charting

A

B

C

D

5. Functional capacity evaluation

A

B

C

D

6. Geriatrics

A

B

C

D

7. Inservice education

A

B

C

D

8. Wheelchair/equipment assessment

A

B

C

D

9. Work Capacity evaluation

A

B

C

D

A. Newborn/Neonate (birth - 30 days)
B. Infant (30 days - 1 year)
C. Toddler (1 - 3 years)
D. Preschooler (3 - 5 years)
E. School age children (5 - 12 years)
F. Adolescents (12 - 18 years)
G. Young adults (18 - 39 years)
H. Middle adults (39 - 64 years)
I. Older adults (64+)

Able to adapt care to incorporate normal growth and development.

A

B

C

D

E

F

G

H

I

Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.

A

B

C

D

E

F

G

H

I

Can ensure a safe environment reflecting specific needs of various age groups.

A

B

C

D

E

F

G

H

I

Certification: (mo/day/year)

BCLS

Exp Date:

CPR

Exp Date:

Other

Other Type

Exp Date:

Computerized charting system

Exp Date:

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Physical Therapy Skills Checklist to their Client facilities in relation to consideration of employment as a Traveler with those facilities.

Signature *

Date