• The purpose of this checklist is to more clearly outline the Physical Therapist's areas of expertise. Please complete this checklist as accurately as possible.


  • Certifications and Expiration Date

    If none, please put n/a.


  • Please indicate your level of experience.

    A. ORTHOPEDICS

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • Rehabilitation of patient with:

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • B. SPORTS MEDICINE

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • C. NEUROLOGIC

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • D. MODALITIES

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • E. MANUAL SKILLS

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • F. PROSTHETICS/ORTHOTICS

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • G. PEDIATRICS

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • H. COMPUTERIZED TESTING

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • I. OTHER

  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience
  • Theory, No PracticeIntermittent Experience1-2 Years of ExperienceMore Than 2 Years of Experience

  • EXPERIENCE WITH AGE GROUPS


  • TOTAL YEARS OF EXPERIENCE WITH SETTINGS


    I am the individual completing this form. By checking this box I authorize MAS Medical Staffing to release this checklist to client facilities in consideration for employment.