* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
* First
Middle Initial
Profession PT PTA
Registry Eligible Yes No
Please Mark Your Level of Experience 1 - No Experience 2 - Limited Experience (Assistance Needed) 3 - Some Experience (Needs Resource for Backup) 4 - Very Experienced (Requires No Supervision)
Work Settings
1
2
3
4
General Acute Care
Home Health
Nursing Home
Outpatient Clinic
Pediatric Rehab
Acute Rehab Hospital
Rehab Unit in Hospital
School System
Modalities
Biofeedback
Continuous Passive Motion Machine
Cryotherapy
Ergometer
Fluidotherapy
Hot/Cold Packs
Hubbard Tank
Massage Therapy
Muscle Stimulation
Myofacial Release Technique
Neuromuscular Reeducation
Paraffin
Sterilization Technique
TBMS
Traction - Cervical
Traction - Lumbar
Ultrasound
Whirlpool
Wound Dressing / Debridement
Neuro
Cerebral Vascular Accident
Coma Patients
Head Trauma
Spinal Cord Injury
Parkinson's Disease
Traumatic Brain Injury
Ortho
Arthritis Programs
Back Syndrome
Gait Training
Hand Injury
Hip Fractures
Mobilization Techniques
Neck Injuries
TMJ Dysfunction
Total Hip / Total Knee
Total Joint Replacement
Pediatrics
Adaptive Equipment Assessment
Cerebral Palsy
Developmental Disability Sequencing Test
Early Intervention
Equipment Assessment - Activities of Daily Living
Equipment Assessment
Learning Disabilities
NDT Bobath Testing
NICU Treatment
Orthotics
Spina Bifida
Autism
Prosthetics/Orthotics
AK Prosthetics
Amputees
Ankle Foot Orthosis
BK Prosthetics
Bracing / Joint Immobilization
Dynamic Splinting
Orthoplast
Resting Splints
Serial / Inhibitor Casting
Static Splinting
UE Prosthetics
Sports Medicine
Biodex
Cybex
Lido
Nautilus / Eagle
Orthotron / Kinetron
Strength & Endurance Testing
Taping / Strapping
Other
AIDS Patients
Burn Management
Cardiac Rehabilitation
Chest Physiotherapy
Function Capacity Evaluation
Geriatrics
Inservice Education
Manual Therapy
Medicare 'A' Documentation
Medicare 'B' Documentation
Neonatalogy
Pain Management
Physical Capacity
Pre-Employment Testing
Work Capacity
Work Hardening
Pulmonary Rehab
Other Skills / Credentials Please list any aditional experience or skills that have not been included above:
* Signature (Please Type Full Name)
* Date
