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PT	PTA
OT	OTA
SLP	CFY

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1 = No Experience		3 = Experienced
2 = Intermittent Experience		4 = Supervise and Teach

Adult/Geriatrics	1	2	3	4
Neck/Back Syndromes
Hip fractures
Total Joint Replacement
Total Hip Replacement
Hand Injuries
TMJ
Arthritis Programs	1	2	3	4
Osteoarthritis
Rheumatoid Arthritis
Degenerative Joint Disease
Neurology	1	2	3	4
Stroke Rehabilitation
Head Trauma
Spinal Cord Injury
Functional Splinting
Adaptive Equipment
Peripheral Nerve Injury
Multiple Sclerosis
Parkinsons Disease
Alzheimers Disease
Cardiopulmonary/Circulatory	1	2	3	4
Cardiac Rehab
Myocardial Infarction
Congestive Heart Failure
Emphysema
Chronic Obstructive Pulmonary Disease
Lymphedema
Peripheral Vascular Disease
Sports Medicine	1	2	3	4
Athletic Injuries
Recreational Injuries
Biodex
Cybex
Orthotron
Lido
Nautilus
Taping
Work Place Injury	1	2	3	4
Work Hardening
Work Capacity Evaluation
Functional Capacity Evaluation
Ergonomics
Carpal Tunnel Syndrome
Cumulative Trauma
Stress Disorders
Prosthetics/Orthotics	1	2	3	4
Above Knee Prosthetics
Below Knee Prosthetics
Upper Extremity Prosthetics
Foot Orthosis
Splints
Upper Extremity Splinting
Static
Dynamic
Orthotic Prescriptions
Modalities/Procedures	1	2	3	4
Mobilization
Spinal
Extremity
Myofacial Release
Craniosacral Techniques
Continuous Passive Motion Machines
Hydrotherapy
Whirlpool
Hubbard Tank
Therapeutic Pool
Traction
Cervical
Lumbar
Massage
Ultrasounds
TENS
Biofeedback
Diathermy
Electrical Stimulation
Cryotherapy
Acupressure
Other	1	2	3	4
Wound Management
Chest PT
Cancer
AIDS
Isolation Precautions
ICU CCU SICU Procedures
Skilled Nursing Documentation
Skilled Nursing Documentation
Medicare A
Medicare B
Medicaid
Quality Improvement
Management Administration
Pediatrics/Othopedics	1	2	3	4
Fractures
Fractures
Birth Defects
Development Diseases of the Bone
Taping
Crutch Training
Modalities	1	2	3	4
CPM Machines
Hydrotherapy
Neurologic	1	2	3	4
Developmental Disabilities Sequencing Test
Neurodevelopmental Techniques
Head Injury
Spinal Cord Injury
Spasticity Management
Prosthetics/Orthotics	1	2	3	4
Bracing
Splinting
Prosthetics
Orthotics
Experience in the Following Practices	1	2	3	4
General Acute Care Hospital
Pediatric Hospital or Clinic
Rehab
Home Health
Skilled Nursing Facilities
Long Term Care
Private Practice
Outpatient Clinics
Hospice Program
Corporate Industrial Medical Centers
Occupational Environment
Physician's Office
Sports Injury Treatment Center
Fitness Center
Research Center
Preschool System
Vocational Rehab

National Specialization Certification	Date Certified
Cardiopulmonary
Clinic Electrophysiology
Geriatrics
NDT
Orthopedics
Pediatrics
Sports Physical Therapy
Athletic Trainer Certified
Other

Education
1. Graduated From
Degree
2. Graduated From
Degree

Licenses
License Number
Expiration
State

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