PT/PTA Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyAdult - OrthopedicNeck Injuries / Surgeries 1 2 3 4 Back Injuries / Surgeries 1 2 3 4 Hip Fractures / Injuries 1 2 3 4 Total Hip Replacement 1 2 3 4 Knee Injuries 1 2 3 4 Total Knee Replacement 1 2 3 4 Upper Extrem Joint Replacements 1 2 3 4 Shoulder Injuries 1 2 3 4 Degen. Joint Disease / Arthritis 1 2 3 4 Hand Injuries 1 2 3 4 Temporomandibular Joint (TMJ) 1 2 3 4 Post Operative Care 1 2 3 4 Amputations 1 2 3 4 Adult - NeurologicStroke Rehabilitation 1 2 3 4 Cognitive Disorders 1 2 3 4 Head Trauma 1 2 3 4 Spinal Cord Injury 1 2 3 4 Functional Splinting 1 2 3 4 Adaptive Equipment-Wheelchair 1 2 3 4 Neuromuscular Diseases 1 2 3 4 Multiple Sclerosis 1 2 3 4 Adult - Prosthetics / OrthoticsUpper Extremity Prosthetics 1 2 3 4 Above Knee Prosthetics 1 2 3 4 Below Knee Prosthetics 1 2 3 4 Sports MedicineLIDO 1 2 3 4 Nautilus / Eagle 1 2 3 4 Taping 1 2 3 4 Sports Medicine - Prosthetics / OrthoticsOther 1 2 3 4 Chest PT 1 2 3 4 Cardiac Rehab 1 2 3 4 ICU Procedures 1 2 3 4 CCU Procedures 1 2 3 4 SICU Procedures 1 2 3 4 Burn Management 1 2 3 4 Work Hardening - Work Site Eval 1 2 3 4 Work Capacity Eval 1 2 3 4 Procedures / TreatmentsAnkle / Foot Orthosis 1 2 3 4 Slings 1 2 3 4 Splints - Wrist / Hand 1 2 3 4 CPM Machine 1 2 3 4 Hydrotherapy 1 2 3 4 Whirlpool 1 2 3 4 Hubbard Tank 1 2 3 4 Therapeutic Pool 1 2 3 4 TENS 1 2 3 4 Electrical Stimulation 1 2 3 4 Ultrasound 1 2 3 4 Cryotherapy 1 2 3 4 Massage 1 2 3 4 Diathermy 1 2 3 4 Acupressure 1 2 3 4 Spinal Mobilization 1 2 3 4 Extremity Mobilization 1 2 3 4 Myofacial Release 1 2 3 4 Craniosacral Techniques 1 2 3 4 Cervical Traction 1 2 3 4 Lumbar Traction 1 2 3 4 Activities of Daily Living 1 2 3 4 Gait Training 1 2 3 4 Transfers 1 2 3 4 Sports Medecine 1 2 3 4 Athletic Injuries 1 2 3 4 Biodex 1 2 3 4 Cybex 1 2 3 4 Orthotron 1 2 3 4 OtherFunctional Capacity Eval 1 2 3 4 Muscle Energy Techniques 1 2 3 4 Activities of Daily Living 1 2 3 4 Universal Precautions 1 2 3 4 Skilled Nursing Documentation 1 2 3 4 Medicare A 1 2 3 4 Medicare B 1 2 3 4 State Healthcare 1 2 3 4 Skilled Nursing Documentation 1 2 3 4 Age Specific CompetenciesNewborn (Birth-30 days) 1 2 3 4 Infant (30 days - 1 year) 1 2 3 4 Toddler (1 - 3 years) 1 2 3 4 Preschooler (3 - 5 years) 1 2 3 4 School Age (5 - 12 years) 1 2 3 4 Adolescents (12 - 18 years) 1 2 3 4 Young Adults (18 - 39 years) 1 2 3 4 Middle Adults (39 - 64 years) 1 2 3 4 Older Adults (64+ years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this PT/PTA Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
