PHYSICIAN ASSISTANT CHECKLIST
  PHYSICIAN ASSISTANT CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
       
Rating Stars (Click) Populations Worked With 1 2 3 4  
Neonatal  
Pediatrics  
Adolescent  
Geriatric  
Adult  
Rating Stars (Click) Cardiovascular 1 2 3 4  
Anaphalaxis  
Cardiac Arrest  
Seizures  
Minor Head Injuries  
Animal Bites  
Ingestions & Poisonings  
Overdose. Sedatives, Opiates  
Snake Bites  
Minor Burns  
Open Wounds  
Shock  
Rating Stars (Click) Respiratory 1 2 3 4  
Croup  
Tracheobronchitis  
Influenza  
Bronchitis  
COPD  
Pneumonia  
Asthma  
Sinusitis  
URI (Upper Respiratory Infection)  
Rating Stars (Click) Cardiovascular System 1 2 3 4  
Congestive Heart Faliure  
COPD  
Stasis Ulcer of Lower Extremeties  
Pericarditis  
Angina  
Coronary Artery Disease  
Functional Murmurs  
Congenial Heart Disease  
Hypertension  
Rating Stars (Click) OB/GYN 1 2 3 4  
Nausea/Vomiting with Pregnancy  
Dysmenorrhea  
Candida Vaginitis  
Pap Smears  
Abnormal Pap Smear Findings  
Trichomonal Vaginitis  
Menopause  
Bartholin's Cyst/Abscess  
Preparation for Child Birth  
Pregnancy, Diagnosis & Referral  
Pain Relief in Active Labor  
Intrapartum Medications  
Medications in 3rd Stage  
Dysfunctional Uterine Bleeding  
RH Blood Factor  
Mastitis  
Medication in Postpartum Stage  
Birth Control Methods  
Fetal Well-Being  
Pre-Natal Care  
Middle Adults (39-64 Years)  
Rating Stars (Click) GI System 1 2 3 4  
Constipation  
Diarrhea (Simple)  
Irritable Bowel Syndrome  
Acute Gastroenteritis  
Hiatal Hernia  
Hemorrhoids  
Duodenal Ulcer  
Hepatitis  
Cholecystitis  
Pyloric Stenosis  
Colic  
Appendicitis  
Rating Stars (Click) Skin 1 2 3 4  
Warts  
Basal Sin Crcinonma  
Scabies  
Impetigo  
Diaper Dematitis  
Acne  
Folliculitis  
Furuncles  
Carbuncles  
Herpes Simple  
Herpes Zoster  
Malignant Melanoma  
Pityrasis Rosea  
Contact Dermatitus  
Tinea Coropris  
Tinea Pedis  
Rating Stars (Click) Ear, Nose, and Throat 1 2 3 4  
Epistaxis  
Otitis Eterna  
Serious Otitis Media  
Allergichrhinitis  
Pharyngitis  
Oral Candidiasis  
Rating Stars (Click) Eye 1 2 3 4  
Conjuctivitis  
Stabismus  
Chalazion  
Stye  
Rating Stars (Click) Musculoskeletal 1 2 3 4  
Osteoporosis  
Osteomyelitis  
Rheumatoid Arthritis  
Juvenile Diabetes  
Gout  
Minor Sprains Á Strains  
Osteoarthritis  
Carpal Tunnel Syndrome  
Scholiosis  
Tendonitis  
Muscular Dystrophy  
Rating Stars (Click) Parasitic Infections 1 2 3 4  
Pinworms  
Ascariasis  
Pediciolis  
Rating Stars (Click) Genitourinary System 1 2 3 4  
Syphilis  
Chlamydia  
Herpes  
Cystitis  
Pyelonephritis  
Urinary Tract Infection  
Benign Prostatic Hypertrophy  
Vulvovaginitis    
Hypospadias  
Hydrocele  
Gonococcal Infections  
Prostatitis  
Rating Stars (Click) Nervous Systems 1 2 3 4  
Vaginal Syncope  
Migraine Headaches  
Multiple Sclerosis  
Headaches  
Head Injury  
Anxiety  
Bell's Palsy  
TIA (Transient Ischemic Attacks)  
Trigeminal Sclerosis  
Multiple Sclerosis  
Rating Stars (Click) Endocrine 1 2 3 4  
Type I Diabetes Mellitus  
Type II Diabetes Mellitus  
Graves Disease  
Addison's Disease  
Juvenile Diabetes  
Hypoglycemia  
Hypothyroidism  
Rating Stars (Click) Hematological 1 2 3 4  
Aplastic Anemia  
Iron Deficiency  
Sickle Cell Anemia  
Pernicious Anemia  
Rating Stars (Click) Psychosocial 1 2 3 4  
Depression  
Suicide  
Grief  
Anxiety  
Bulimia  
Rating Stars (Click) Age Appropriate Care 1 2 3 4  
Newborn (Birth-30 Days)  
Infant (30 Days - 1 Year)  
Toddler (1-3 Years)  
Preschooler (3-5 Years)  
School Age (5-12 Years)  
Adolescents (12-18 Years)  
Young Adults (18-39 Years)  
Middle Adults (39-64 Years)  
Older Adults (64+ Years)