PHYSICAL THERAPY SKILLS CHECKLIST
Name:
When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill.

The scale is as follows:
1. Not performed   2. Intermitten experience   3. Very experienced.
ACCREDITING AGENCY:
  1. FSBPT   1 2 3
  2. OTHER:   1 2 3
CERTIFICATIONS:
  1. BLS   1 2 3
  2. ACLS   1 2 3
EXPERIENCE IN PRIMARY AREAS:
  1. Hospitals   1 2 3
  2. Clinics   1 2 3
  3. Nursing Homes   1 2 3
  4. Home Health   1 2 3
MODALITIES/MANUAL SKILLS:
  1. Acuscope   1 2 3
  2. Biofeedback   1 2 3
  3. Continuous Passive Motion Machine   1 2 3
  4. Craniosacral Therapy   1 2 3
  5. Cryotherapy   1 2 3
  6. Diathermy   1 2 3
  7. Electro-acupuncture   1 2 3
  8. Extremity Mobilization   1 2 3
  9. Fluidotherapy   1 2 3
  10. Hot/cold packs   1 2 3
  11. Hubbard tank   1 2 3
  12. Therapeutic pool   1 2 3
  13. Whirlpool   1 2 3
  14. Massage   1 2 3
  15. Muscle energy techniques   1 2 3
  16. Muscle stimulation   1 2 3
  17. Myofascial release techniques   1 2 3
  18. Neuro probe   1 2 3
  19. Parafin   1 2 3
  20. Spinal Mobilization   1 2 3
  21. Strain/counter strain techniques   1 2 3
  22. TENS   1 2 3
  23. Therapeutic exercise/home programs   1 2 3
  24. Cervical traction   1 2 3
  25. Lumbar traction   1 2 3
  26. Ultrasound   1 2 3
  27. Vasopneumatic devices   1 2 3
  28. Wound dressing   1 2 3
  29. NCV; EMG (non-invasive)   1 2 3
NEUROLOGIC:
  1. Head trauma   1 2 3
  2. Neurosurgery   1 2 3
  3. Spinal Cord Injuries   1 2 3
  4. Stroke Equipment   1 2 3
  5. Adaptive Equipment   1 2 3
  6. Functional Splinting   1 2 3
ORTHOPEDIC:
  1. Arthritis Programs   1 2 3
  2. Back Syndromes   1 2 3
  3. Hand Injuries   1 2 3
  4. Hip Fractures   1 2 3
  5. Mobilization Techniques   1 2 3
  6. Neck Injuries   1 2 3
  7. Total Hip/Knee Replacement   1 2 3
  8. Total Joint Replacement/upper extremities   1 2 3
  9. Transmandibular Joint Dysfunction   1 2 3
PROSTHETICS/ORTHOTICS:
  1. Above knee prosthetics   1 2 3
  2. Ankle foot orthosis   1 2 3
  3. Below knee prosthetics   1 2 3
SPORTS MEDICINE:
  1. Biodex   1 2 3
  2. Bracing/Joint Immobilization   1 2 3
  3. Cybex   1 2 3
  4. LIDO   1 2 3
  5. Nautilus/Eagle   1 2 3
  6. Orthotron   1 2 3
  7. Strength and Endurance Training   1 2 3
  8. Taping/Strapping   1 2 3
AGE APPROPRIATE NURSING CARE
Please check the appropriate box(es) for each age group and activity for which you have had experience within the last year.

Age Specific Experiences Adolescent(13-18 yrs)Young Adult(19-39 yrs) Middle Adults(40-64 yrs)Older Adult(65+ yrs)
1. Understands the normal growth and development for each age group and adapts care accordingly
2. Understands the different communication needs for each age group and changes communication methods and terminology accordingly
3. Understands the different safety risks for each age group and alters the environment accordingly
4. Understands the different medications, dosages and possible side effects for each age group and administers medications appropriately


The information I have given is true and accurate to the best of my knowledge. Please sign and date below.
SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN:   DATE:

  
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