PT/LPTA Skills Checklist First name: Middle Name: Last Name: Last 4 of SSN# Email Address: Phone # Please indicate your level of experience based on No experience (1) to perform independently (4) 1. No theory and/or experience 2. Limited experience/need supervision and/or support 3. Experienced/minimal support needed to perform 4. Proficient/can perform independently Work setting experiences: Please circle 1-4 next to each facility based on experience Skilled Nursing General Acute Care Long Term Acute Care Inpatient Rehabilitation Hospital Outpatient Rehabilitation Sports Medicine Clinic Rehabilitation Clinic Pediatric Inpatient/Outpatient School System Home Health Care Psychiatric Care Hand Therapy Clinic Orthopedic: Circle 1-4: No experience (1) to perform independently (4) Hand Injury Hip Fractures Mobilization Techniques Therapeutic Exercises Total Hip/Knee Replacement Total Joint Replacement Upper/Lower Extremities Neck Injuries Back Syndromes Transmandibular Joint Dysfunction
Arthritis Program: Circle 1-4: No experience (1) to perform independently (4) Joint Protection Energy Conservation techniques Neurologic: Head trauma Neurosurgery Spinal Cord Injury Stroke Rehabilitation Adaptive Equipment Functional Splinting Sports Medicine: Circle 1-4; No experience (1) to perform independently (4) Biodex Bracing/Joint Immobilization Cybex LIDO Nautilus/Eagle Orthotron Strength and Endurance Training Tapping/Strapping Modalities/Manual Skills: Circle 1-4; No experience (1) to perform independently (4) Biofeedback Cryotherapy Craniosacral Therapy Continuous Passive Motion Machine Acuscope Diathermy Electro-Acupuncture Extremity Mobilization Fluidotherapy Hot/cold packs Massage Muscle Energy Techniques Muscle Stimulation Myofascial Release Techniques Neuro Probe Paraffin
Spinal Mobilization Strain/Counter Strain Techniques TENS Therapeutic Exercise/Home Programs Ultrasound Vasopneumatic Devices Wound Dressing Hydrotherapy Hubbard Tank Therapeutic Pool Whirl Pool Traction: Circle 1-4; No experience (1) to perform independently (4) Cervical Lumbar Prosthetics/Orthotics: Circle 1-4; No experience (1) to perform independently (4) Above Knee Prosthetics Below Knee Prosthetics Ankle Foot Orthosis Dynamic Splints Gait Analysis Orthoplast/Aquaplast Resting Splints Serial/Inhibitory Casting Static Splints Upper Extremity Prosthetics Pediatrics: Circle 1-4; No experience (1) to perform independently (4) Cerebral Palsy Early Intervention Gross Motor Assessment Learning Disabled Mental Retardation Neurodevelopmental treatment Orthotics Spinal Bifida
Computerized Testing: Circle 1-4; No experience (1) to perform independently (4) Functional strength ROM Net Muscular Torque Fatigue Characteristics Net Muscular Torque Work Capacity Miscellaneous: Circle 1-4: No experience (1) to perform independently (4) Computerized Charting Burn Management Wound Management Cardiac Rehabilitation Drivers Evaluation and Education RUG Levels Chest Physiotherapy Inservice education Functional Capacity Evaluation Wheelchair and Equipment Assessment Work Capacity Evaluation Experience in months or years in the following Settings: Circle Months or years Skilled Nursing Facility: Acute Rehabilitation: Home Health Care: School Systems: Outpatient Therapy: Pediatrics Therapy: Certifications, Licensures, and Registrations: Month/Day/Year ATC: NDT: CPR: Please read and agree to the statements below by placing your initials at the end of the statement. I attest that the information provided is true and accurate to the best of my knowledge. I hereby authorize Nationwide Therapy Group to release the Skills Checklist to the facilities for placement purposes.
First Name: Last Name: Signature: (Signature on File) Date: