Physical Therapist Self Assessment Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Work Settings	Rating Stars (Click)	1	2	3	4
Adult/adult ICU
Children�s hospital
General acute care
Home health care
Outpatient neuro
Outpatient ortho
Pediatrics/PICU
Psychiatric hospital
Rehabilitation hospital
School setting
Orthopedics	Rating Stars (Click)	1	2	3	4
Upper extremities
Arthritis programs
Back syndrome
Cervical injuries
Chronic fatigue syndrome
Fibromyalgia
Halo traction
Hand injury
Orthopedics - cont.	Rating Stars (Click)	1	2	3	4
Manual therapy
Mobilization techniques
Pelvic fracture
Postpolio syndrome
Shoulder injuries
TMJ dysfunction
Total hip/total knee
Total joint replacement
Total shoulder/CPM
Neurologic	Rating Stars (Click)	1	2	3	4
ALS
Brain tumors
Cerebral palsy
Multiple sclerosis
Muscular dystrophy
Polio/post polio syndrome
Spinal cord injury
Adaptive equipment
Functional splinting
Neurodevelopmental testing (NDT)
Head trauma
Pediatrics	Rating Stars (Click)	1	2	3	4
Activities of daily living
Adaptive
Developmental disability
Equipment assessment
Individualized education programs
Neurodevelopmental testing (NDT)
Orthotics
Sequencing testing
Sports Medicine	Rating Stars (Click)	1	2	3	4
Biodex
Bracing/joint
Cybex
Immobilization
Lido
Medical expenses (Norwegian)
Nautilus/eagle
Orthotron/kinetron
Stabilization techniques
Swiss ball
Taping/strapping
Prosthetics/Orthotics	Rating Stars (Click)	1	2	3	4
Dynamic splints
LE prosthetics
Protonics
Removeable rigid dressings
Serial casting
Static splints
UE prosthetics