orthopedic sports medicine · ethika group, llc 2351 w northwest hwy suite 3270 dallas tx 75220...
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Ethika Group, LLC 2351 W Northwest Hwy Suite 3270 Dallas TX 75220 Phone: 972-661-0883 Fax: 972-692-7202
Physical Therapist/ Assistant Skills Checklist
Name:
State Licenses:
Please List all of the documentation systems you are proficient in:
Levels of Experience: Use the following values to rate your level of experience and/or frequency within the last two years. 1 = No Experience 2 = Limited Experience/ Supervision or Support
3 = Experienced/ Needs Minimal Support 4 = Proficient/ Performs Independently
Work Settings 1 2 3 4 1 2 3 4
Acute Care Hospital
Rehab Hospital/ Sub-Acute
Extended Care Facility
Assisted Living
Skilled Nursing Facility
Hospital Outpatient
Outpatient Clinic
Home Healthcare
School Setting
Pediatrics
Orthopedic
1 2 3 4 1 2 3 4
Arthritis Programs
Back Syndrome
Hand Injury
Hip Fractures
Mobilization Techniques
Neck Injuries
Total Hip/Knee Replace
Total Joint Replace
Upper Exremities
Trasmandibular Joint Dysfunction
Sports Medicine
1 2 3 4 1 2 3 4
Biodex Taping/Strapping
Bracing/ Joint Immobilization Endurance Training
Cybex Strength Training
LIDO Nautilus/Eagle
Orthotron
Ethika Group, LLC 2351 W Northwest Hwy Suite 3270 Dallas TX 75220 Phone: 972-661-0883 Fax: 972-692-7202
Modalities/ Manual Skills
1 2 3 4 1 2 3 4
Acuscope Passive Motion Machine
Craniosacral Therapy Cryotherapy
Biofeedback Diathermy
Electro-Acupuncture Extremity Mobilization
Fluidotherapy Hot/Cold Packs
Hydrotherapy Massage
Muscle energy Technique Myofascial release Technique
Neuro Probe Paraffin
Spinal Mobilization Strain/Counter Strain
TENS Therapeutic Exercise
Traction Cervical Traction Lumbar
Ultrasound Vasopneumatic Device
Wound Dressing Home Programs
Neurologic
1 2 3 4 1 2 3 4
Head Trauma Adaptive Equipment
Neurosurgery Functional Splinting
Spinal Cord Injury Traumatic Brain Injury
Stroke Rehab Parkinson’s Disease
Prosthetics/Orthotics
1 2 3 4 1 2 3 4
Above knee Ankle/ Foot
Below Knee Dynamic Splinting
Gait Analysis Orthoplast/ Aquaplast
Resting Splints Serial/Inhibitory casting
Static Splinting Upper extremity
Lower extremity Joint Immobilization
Ethika Group, LLC 2351 W Northwest Hwy Suite 3270 Dallas TX 75220 Phone: 972-661-0883 Fax: 972-692-7202
Pediatrics
1 2 3 4 1 2 3 4
Cerebral Palsy Early Intervention
Equipment assess adaptive Gross motor assess tools
Leaning disabled Mental retardation
Neurodevelopment treatment Orthotics
Spina bifida NICU treatment
Computerized Testing
1 2 3 4 1 2 3 4
Fatigue characteristics Fiber type
Functional strength Net muscle torque
ROM Work Capacity
Other
1 2 3 4 1 2 3 4
Burn management Cardiac rehab
Chest physiotherapy Computerized charting
Functional capacity evaluation Geriatrics
In-service Education Wheelchair assessment
Medicare “A’ Document Medicare “B” Document
RUG Levels Medicaid Billing
Work capacity evaluation Pain Management
By checking this box, I attest that the information given is true and accurate to the best of my knowledge and that I am the individual completing this form. I verify that the representation of my skills associated proficiency levels in this document are a true and accurate reflection of my abilities based on my work experience.