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Clinical Experience Form

Evaluation Procedures Notes Observation


Upper Quarter Scan N/A
Cervical N/A
Shoulder N/A
TMJ N/A
Elbow, Wrist, Hand N/A
Lower Quarter Scan N/A
Lumbar Spine N/A
SI Joint N/A
Hip N/A
Knee N/A
Foot & Ankle N/A
Adult - Vestibular N/A
Adult - Balance N/A
General Deconditioning N/A
Fall Risk N/A
Orthotic Evaluation N/A
Integumentary N/A
Aerobic Capacity / Endurance N/A
Range of Motion N/A
Strengthening Exercise N/A
Aerobic Capacity / Endurance Conditioning N/A
Balance and Coordination N/A
Postural Stabilization N/A
Neuro-muscular Re-education N/A
Home Exercise Programs N/A
Bed Mobility N/A
Transfers N/A
Wheelchair Mobility N/A
Gait Training N/A
Body Mechanics N/A
Superficial Heat/Cold Modalities N/A
Ultrasound N/A
Electrotherapeutic Modalities N/A
Traction N/A
Extremity Joint Mobilization N/A
Spine Mobilization N/A
Soft Tissue Mobilization N/A
Other: 1 Muscle Energy Techniques N/A
Other: 2 Active Release N/A
Cardiac Rehabilitation N/A
Neuro-Developmental Techniques N/A
Safety Procedures N/A
Assistive Device Prescription 6/12/2015
Family Education N/A
Patient Specific Functional Scale N/A
Global Rating of Improvement N/A
Other1 N/A
Other2 N/A
Neck Disability Index N/A
Oswestry N/A
Lower Extremity Functional Scale N/A
Dizziness Handicap Inventory (DHI) N/A
Timed Up and (TUG) N/A
Berg Balance Scale N/A
Single Limb Stance N/A
Scheduling patients N/A
Gathering information from chart N/A
Writing initial evaluations N/A
Writing progress notes N/A
Writing home instructions N/A
team communication N/A
interdisciplinary coordination of patient care N/A
understanding roles and responsibilities of team members N/A
Experience Form

Novice Advanced beginnerCompetent Proficient


N/A 7/5/2016 N/A 8/19/2016
N/A 7/5/2016 8/19/2016 5/5/2017
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6/12/2015 N/A N/A 8/19/2016
N/A N/A 8/19/2016 5/5/2017
N/A 6/12/2015 5/5/2017 N/A
N/A 6/12/2015 5/5/2017 N/A
6/12/2015 N/A 8/19/2016 5/5/2017
N/A 6/12/2015 N/A 8/19/2016
6/12/2015 7/5/2016 N/A 8/19/2016
6/12/2015 7/5/2016 N/A 5/5/2017
6/12/2015 7/5/2016 N/A 8/19/2016
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N/A 7/5/2016 8/19/2016 5/5/2017
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6/12/2015 N/A 5/5/2017 N/A
N/A 7/5/2016 8/19/2016 5/5/2017
N/A N/A 7/5/2016 8/19/2016
N/A N/A N/A 5/5/2017
6/12/2015 N/A N/A 5/5/2017
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N/A 7/5/2016 N/A 8/19/2016
N/A 6/12/2015 5/5/2017 N/A
N/A 6/12/2015 7/5/2016 8/19/2016
N/A 6/12/2015 8/19/2016 5/5/2017
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N/A N/A 7/5/2016 8/19/2016
6/12/2015 6/12/2015 8/19/2016 5/5/2017
6/12/2015 N/A N/A 5/5/2017
N/A 6/12/2015 N/A 8/19/2016