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Physical Therapist
Physical Therapist/PTA
Name
First
Last
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
Orthopedics
No Experience
Limited Experience
Experienced
Highly Skilled
Bracing
Equipment - Support device - Crutch training
Equipment - Support device - Slint
Orthotics
Respiratory Treatments
No Experience
Limited Experience
Experienced
Highly Skilled
Perform - Chest physiotherapy
Therapy - Pediatrics
No Experience
Limited Experience
Experienced
Highly Skilled
Care of child - Burn Care
Care of child - Cerebral Palsy
Care of child - Cystic Fibrosis
Care of child - Muscular Dystrophy
Care of child - Spina Bifada
Care of child - Trauma
Care of child - Traumatic Brain Injury
Critical Care Procedures
Hearing Impairments
Isolation Precautions
Neurologic - Congenital Defects
Neurologic - Developmental Disabilities Sequencing Test
Neurologic - Head Injury
Neurologic - Neurodevelopmental Deficits
Neurologic - Neurodevelopmental Techniques
Neurologic - Sensory Integrative Deficits
Neurologic - Spinal Cord Injury
Neurologic - Visual Perceptual Disorders
Orthopedics - Birth Defects
Orthopedics - Developmental Disease of Bone
Orthopedics - Fractures
Procedure / Treatment - Adaptive Equipment Training
Procedure / Treatment - Adaptive Equipment Assessment
Procedure / Treatment - CPM Machine
Procedure / Treatment - Dynamic Splints
Procedure / Treatment - Hydrotherapy
Procedure / Treatment - Postural Balance Training
Procedure / Treatment - Resting Splints
Procedure / Treatment - Sensory Integration Techniques
Procedure / Treatment - Splinting - Hand
Procedure / Treatment - Splinting - Lower Extremity
Procedure / Treatment - Splinting - Wrist
Procedure / Treatment - Vision Therapy
Prosthetics - Lower Extremity Prosthetics
Prosthetics - Upper Extremity Prosthetics
Therapy - Adult
No Experience
Limited Experience
Experienced
Highly Skilled
Burn Management
Cardiac Arrest
Care of patient - Degenerative Disease
Care of patient - Multiple Sclerosis
Care of patient - Traumatic Brain Injury
Neurologic - Adaptive Equipment - Wheelchair
Neurologic - Cognitive Disorders
Neurologic - Head Trauma
Neurologic - Neuromuscular Disease
Neurologic - Spinal Cord Injury
Neurologic - Stroke Rehabilitation
Orthopedic - Amputations
Orthopedic - Back Injuries/Surgeries
Orthopedic - Hand Injury
Orthopedic - Hip Fractures/Injuries
Orthopedic - Knee Injuries
Orthopedic - Neck Injuries/Surgeries
Orthopedic - Post operative care
Orthopedic - Shoulder Injury
Orthopedic - TMJ
Orthopedic - Total Hip Replacement
Orthopedic - Total Knee Replacement
Orthopedic - Upper Extremity Joint Replacement
Procedure / Treatment - Activities of Daily Living
Procedure / Treatment - Acupressure
Procedure / Treatment - Cervical Traction
Procedure / Treatment - CPM Machine
Procedure / Treatment - Cranialsacral Techniques
Procedure / Treatment - Cryotherapy
Procedure / Treatment - Diathermy
Procedure / Treatment - Electric Stimulation
Procedure / Treatment - Extremity Mobilization
Procedure / Treatment - Functional - Capacity Evaluation
Procedure / Treatment - Functional - Dynamic Splinting
Procedure / Treatment - Gait Training
Procedure / Treatment - Hubbard Tank
Procedure / Treatment - Hydrotherapy
Procedure / Treatment - Lumbar Traction
Procedure / Treatment - Massage
Procedure / Treatment - Muscle Energy Techniques
Procedure / Treatment - Myofacial Release
Procedure / Treatment - Spinal Mobilization
Procedure / Treatment - Splinting - Hand
Procedure / Treatment - Splinting - Wrist
Procedure / Treatment - TENS
Procedure / Treatment - Therapeutic Pool
Procedure / Treatment - Transfers
Procedure / Treatment - Ultrasound
Procedure / Treatment - Whirlpool
Procedure / Treatment - Work Capacity Evaluation
Prosthetics - Above Knee
Prosthetics - Anke/Foot Orthosis
Prosthetics - Below Knee
Sports Medicine - Athletic Injries
Sports Medicine - Biodex
Sports Medicine - Cybex
Sports Medicine - LIDO
Sports Medicine - Nautilus/Eagle
Sports Medicine - Orthotron
Sports Medicine - Taping
Therapy - Geriatrics
No Experience
Limited Experience
Experienced
Highly Skilled
Burn Management
Cardiac Rehab
Exercise Programs
Neurologic - Adaptive Equipment - Wheelchair
Neurologic - Alzheimers / Dementia
Neurologic - Cognitive Disorders
Neurologic - Head Trauma
Neurologic - Neuromuscular Disease
Neurologic - Spinal Cord Injury
Neurologic - Stroke Rehabilitation
Orthopedics - Amputation
Orthopedics - Arthritis
Orthopedics - Back Injuries/Surgeries
Orthopedics - Hand Injuries
Orthopedics - Hip Fractures/Injuries
Orthopedics - Knee Injuries
Orthopedics - Neck Injuries/Surgeries
Orthopedics - Osteoarthritis
Orthopedics - Post Operative Care
Orthopedics - Shoulder Injury
Orthopedics - Total Hip Replacement
Orthopedics - Total Knee Replacement
Orthopedics - Upper Extremity Joint Replacement
Procedure / Treatment - Activities of Daily Living
Procedure / Treatment - Acupressure
Procedure / Treatment - Cervical Traction
Procedure / Treatment - CPM Machine
Procedure / Treatment - Cranialsacral Techniques
Procedure / Treatment - Cryotherapy
Procedure / Treatment - Diathermy
Procedure / Treatment - Documentation - Medicare A
Procedure / Treatment - Documentation - Medicare B
Procedure / Treatment - Documentation - State Healthcare
Procedure / Treatment - Electric Stimulation
Procedure / Treatment - Extremity Mobilization
Procedure / Treatment - Gait Training
Procedure / Treatment - Hubbard Tank
Procedure / Treatment - Hydrotherapy
Procedure / Treatment - Lumbar Traction
Procedure / Treatment - Massage
Procedure / Treatment - Spinal Mobilization
Procedure / Treatment - Splinting - Hand
Procedure / Treatment - Splinting - Wrist
Procedure / Treatment - Sterilization Techniques
Procedure / Treatment - TENS
Procedure / Treatment - Therapuetic Pool
Procedure / Treatment - Transfers
Procedure / Treatment - Ultrasound
Procedure / Treatment - Whirlpool
Prosthetics - Above Knee
Prosthetics - Ankle/Foot Orthosis
Prosthetics - Below Knee
Upper Extremity Prosthetics
Medical Proficiency
No Experience
Limited Experience
Experienced
Highly Skilled
Documentation
Signature
Δ
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