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Name*

First Last

Phone*

Email*

Setting

Proficiency Rating

Frequency Rating

Acute *

Acute proficiency*

Acute frequency*

Rehab *

Rehab proficiency*

Rehab frequency*

Inpatient *

Inpatient proficiency*

Inpatient frequency*

Outpatient *

Outpatient proficiency*

Outpatient frequency*

Home Health *

Home Health proficiency*

Home Health frequency*

SNF *

SNF proficiency*

SNF frequency*

Schools *

Schools proficiency*

Schools frequency*

Adult

Proficiency Rating

Frequency Rating

ORTHOPEDIC:

Fractures *

Fractures proficiency*

Fractures frequency*

Total Joint Replacement *

Total Joint Replacement proficiency*

Total Joint Replacement frequency*

Osteoarthritis-Frozen Shoulder *

Osteoarthritis-Frozen Shoulder proficiency*

Osteoarthritis-Frozen Shoulder frequency*

Hand Injuries *

Hand Injuries proficiency*

Hand Injuries frequency*

Post Operative Care *

Post Operative Care proficiency*

Post Operative Care frequency*

Amputations *

Amputations proficiency*

Amputations frequency*

NEUROLOGIC:

Stroke Rehabilitation *

Stroke Rehabilitation proficiency*

Stroke Rehabilitation frequency*

Cognitive Disorders *

Cognitive Disorders proficiency*

Cognitive Disorders frequency*

Head Trauma *

Head Trauma proficiency*

Head Trauma frequency*

Spinal Cord Injury *

Spinal Cord Injury proficiency*

Spinal Cord Injury frequency*

Neuromuscular Diseases *

Neuromuscular Diseases proficiency*

Neuromuscular Diseases frequency*

Alzheimer’s Diseases *

Alzheimer’s Diseases proficiency*

Alzheimer’s Diseases frequency*

Adaptive Equipment-Wheelchair *

Adaptive Equipment-Wheelchair proficiency*

Adaptive Equipment-Wheelchair frequency*

PROSTHETICS / ORTHOTICS:

Upper Extremity Prosthetics *

Upper Extremity Prosthetics proficiency*

Upper Extremity Prosthetics frequency*

PROCEDURES / TREATMENTS:

Splinting-Wrist *

Splinting-Wrist proficiency*

Splinting-Wrist frequency*

Splinting-Hand *

Splinting-Hand proficiency*

Splinting-Hand frequency*

Splinting-Elbow *

Splinting-Elbow proficiency*

Splinting-Elbow frequency*

Functional-Dynamic Splinting *

Functional-Dynamic Splinting proficiency*

Functional-Dynamic Splinting frequency*

Adaptive Equipment *

Adaptive Equipment proficiency*

Adaptive Equipment frequency*

Joint Mobilization *

Joint Mobilization proficiency*

Joint Mobilization frequency*

Myofacial Release *

Myofacial Release proficiency*

Myofacial Release frequency*

Soft Tissue Manipulation *

Soft Tissue Manipulation proficiency*

Soft Tissue Manipulation frequency*

Iontophoresis *

Iontophoresis proficiency*

Iontophoresis frequency*

TENS *

TENS proficiency*

TENS frequency*

Hydrotherapy-Whirlpool *

Hydrotherapy-Whirlpool proficiency*

Hydrotherapy-Whirlpool frequency*

Sterilization Techniques *

Sterilization Techniques proficiency*

Sterilization Techniques frequency*

Cryotherapy *

Cryotherapy proficiency*

Cryotherapy frequency*

Wound Management *

Wound Management proficiency*

Wound Management frequency*

Debridement *

Debridement proficiency*

Debridement frequency*

Ultrasound *

Ultrasound proficiency*

Ultrasound frequency*

Phonophoresis *

Phonophoresis proficiency*

Phonophoresis frequency*

Cognitive Techniques *

Cognitive Techniques proficiency*

Cognitive Techniques frequency*

Vision Therapy *

Vision Therapy proficiency*

Vision Therapy frequency*

Neurodevelopment Techniques *

Neurodevelopment Techniques proficiency*

Neurodevelopment Techniques frequency*

Adaptive Equipment Assessment *

Adaptive Equipment Assessment proficiency*

Adaptive Equipment Assessment frequency*

Adaptive Equipment Training *

Adaptive Equipment Training proficiency*

Adaptive Equipment Training frequency*

Feeding Techniques *

Feeding Techniques proficiency*

Feeding Techniques frequency*

Exercise Programs *

Exercise Programs proficiency*

Exercise Programs frequency*

Postural Education *

Postural Education proficiency*

Postural Education frequency*

Home Safety Evaluation *

Home Safety Evaluation proficiency*

Home Safety Evaluation frequency*

Community Re-entry *

Community Re-entry proficiency*

Community Re-entry frequency*

Group Treatment *

Group Treatment proficiency*

Group Treatment frequency*

Geriatric

Proficiency Rating

Frequency Rating

SKILLED NURSING DOCUMENTATION:

Medicare A *

Medicare A proficiency*

Medicare A frequency*

Medicare B *

Medicare B proficiency*

Medicare B frequency*

State Healthcare *

State Healthcare proficiency*

State Healthcare frequency*

OTHER:

Cardiac Rehab *

Cardiac Rehab proficiency*

Cardiac Rehab frequency*

CCU Procedures *

ICU Procedures proficiency*

ICU Procedures frequency*

CCU Procedures *

CCU Procedures proficiency*

CCU Procedures frequency*

SICU Procedures *

SICU Procedures proficiency*

SICU Procedures frequency*

Burn Management *

Burn Management proficiency*

Burn Management frequency*

Work Hardening - Work Site Eval *

Work Hardening - Work Site Eval proficiency*

Work Hardening - Work Site Eval frequency*

Functional Capacity Eval *

Functional Capacity Eval proficiency*

Functional Capacity Eval frequency*

Transfers *

Transfers proficiency*

Transfers frequency*

Gait Training *

Gait Training proficiency*

Gait Training frequency*

Muscle Energy Techniques *

Muscle Energy Techniques proficiency*

Muscle Energy Techniques frequency*

Activities of Daily Living *

Activities of Daily Living proficiency*

Activities of Daily Living frequency*

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

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Date*

Skills/Competences

Proficiency

Frequency

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