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

1 2 3 4

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)

1 2 3 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)

1 2 3 4

Joint Protection

Energy Conservation techniques

Neurologic:

1 2 3 4

Head trauma

Neurosurgery

Spinal Cord Injury

Stroke Rehabilitation

Adaptive Equipment

Functional Splinting

Sports Medicine: Circle 1-4; No experience (1) to perform independently (4)

1 2 3 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)

1 2 3 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)

1 2 3 4

Cervical

Lumbar

Prosthetics/Orthotics: Circle 1-4; No experience (1) to perform independently (4)

1 2 3 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)

1 2 3 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)

1 2 3 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)

1 2 3 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: Months / years

Acute Rehabilitation:

Home Health Care:

School Systems:

Outpatient Therapy:

Pediatrics Therapy:

Months / years

Months / years

Months / years

Months / years

Months / years

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: ___________________ Date: _______________________ (Signature on File)