PTA Checklist Name Date MM slash DD slash YYYY State LicenseState LicenseAlabamaAkaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPenssylvaniaRhode IslandSouth CarlinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPhoneEmail Please list all 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=Experience/Needs Minimal Support 4=Proficient Independently Work Settings 1234Acute Care HospitalRehab Hospital/ Sub-AcuteExtended Care FacilityAssisted LivingSkilled Nursing Facility1234Hospital OutpatientOutpatient ClinicHome HealthcareSchool SettingPediatrics Orthopedic 1234Arthritis ProgramsBack SyndromeHand InjuryHip FracturesMobilization Techniques1234Neck InjuriesTotal Hip/Knee ReplaceTotal Joint ReplaceUpper ExtremitiesTrasmandibular Joint Dysfunction Sports Medicine 1234BiodexBracing/Joint ImmobilizationCybexLIDOOrthrotron1234Taping/StrappingEnduranceStrength TrainingNautilius/Eagle Modalities/Manual Skills 1234AcuscopeCraniosacral TherapyBiofeedbackElectro-AcupunctureFluidotherapyHydrotherapyMuscle Energy TechniqueNeuro ProbeSpinal MobilizationTENSTraction CervicalUltrasoundWound Dressing1234Passive Motion MachineCryotherapyDiathermyExtremely MobilizationHot/Cold PacksMassageMyofascial Release TechniqueParaffinStrain/Counter StrainTherapeutic ExerciseTraction LumbarVaspneumatic DeviceHome Programs Neurologic 1234Head TraumaNeusurgerySpinal Cord InjuryStroke Rehab1234Adaptive EquipmentFunctional SplintingTraumatic Brain InjuryParkinson's Disease Prosthetics/Orthotics 1234Above KneeBelow KneeGait AnalysisResting SplintsStatic SplintingLower Extremity1234Ankle/FootDynamic SplintingOrthoplast/AquaplastSerial/Inhibitory CastingUpper ExtremityJoint Immobilization Pediatrics 1234Cerebral PalsyEquipment Assess AdaptiveLeaning DisabledNeurodevelopment TreatmentSpina Bifida1234Early InterventionGross Motor Assess ToolsMental RetardationOrthoticsNICU Treatment Computerized Testing 1234Fatigue CharacteristicsFunctional StrengthROM1234Fiber TypeNet Muscle TorqueWork Capacity Other 1234Burn ManagementChest PhysiotherapyFunctional Capacity EvaluationIn-Service EducationMedicare "A" DocumentRUG LevelsWork Capacity Evaluation1234Cardiac RehabComputerized ChartingGeriatricsWheelchair AssessmentMedicare "B" DocumentMedicare BillingPain 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. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
