Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
HEALTH MAINTENANCE
Disease & Disability Prevention
(Pediatric & Adult) 0 1 2
Periodic Health Screening (Adult) 0 1 2
Age-specific Health Maintenance
Guidelines (Pediatric) 0 1 2
Principles of Growth & Development
through lifespan 0 1 2
Health Teaching 0 1 2
DISORDERS OF THE SKIN
Acne (Pediatric & Adult) 0 1 2
Atopic Dermatitis (Pediatric & Adult) 0 1 2
Diaper Dermatitis 0 1 2
Seborrheic Dermatitis (Pediatris & Adult) 0 1 2
Folliculitis, Furuncles (Boils),
Carbuncles (Pediatric & Adult) 0 1 2
Herpes Simplex (Pediatric & Adult) 0 1 2
Impetigo (Pediatric & Adults) 0 1 2
Candidiasis (Adult) 0 1 2
Pityriasis Rosea (Pediatric & Adult) 0 1 2
Contact Dermatitis (Pediatric & Adult) 0 1 2
Scabies (Pediatric & Adult) 0 1 2
Tinea Corporis (Ringworm of Nonhairy
Skin) (Pediatric & Adult) 0 1 2
Tinea Pedis (Athlete’s Foot)
(Pediatric & Adult) 0 1 2
Urticaria (Hives)(Pediatric & Adult) 0 1 2
Warts (Pediatric & Adult) 0 1 2
Basal Cell Carcinoma 0 1 2
Malignant Melanoma 0 1 2
DISORDERS OF THE RESPIRATORY SYSTEM
Acute Laryngotracheobronchitis
(Viral Croup) (Pediatric) 0 1 2
Acute Tracheobronchitis (Pediatric) 0 1 2
Acute Bronchitis (Adult) 0 1 2
Influenza (Adult) 0 1 2
Bronchial Asthma (Pediatric) 0 1 2
Bronchial Asthma (Acute attack
in a known adult asthmatic 0 1 2
DISORDERS OF THE RESPIRATORY SYSTEM (CONT)
Chronic Obstructive Pulmonary Disease
(Adult) 0 1 2
Acute Bronchiolitis (Pediatric) 0 1 2
Pneumonia (Pediatric) 0 1 2
Pneumonia: Bacterial, Mycoplasmal,
& Viral (Adult) 0 1 2
Pulmonary Tuberculosis
(Pediatric & Adult) 0 1 2
EMERGENCIES
Anaphylaxis (Pediatric & Adult) 0 1 2
Animal Bites (Pediatric & Adult) 0 1 2
Snake Bites (Pediatric & Adult) 0 1 2
Minor Burns (Pediatric & Adult) 0 1 2
Ingestions & Poisonings (Pediatric) 0 1 2
Overdose of Sedative, Hypnotic,
or Opiate Drugs (Adult) 0 1 2
Shock (Pediatric & Adult) 0 1 2
Small Open Wounds (Pediatric & Adult) 0 1 2
DISORDERS OF THE EARS, NOSE & THROAT
Otitis Externa (Pediatric & Adult) 0 1 2
Acute Purulent Otitis Media
(Pediatric & Adult) 0 1 2
Serous Otitis Media (Pediatric & Adult) 0 1 2
Epistaxis (Pediatric & Adult) 0 1 2
Allergic Rhinitis (Pediatric & Adult) 0 1 2
Pharyngitis (Sore Throat) 0 1 2
(Pediatric & Adult) 0 1 2
Oral Candidiasis (Thrush) (Pediatric) 0 1 2
Bacterial Sinusitis (Adult) 0 1 2
Nonbacterial Sinusitis (Adult) 0 1 2
Upper Respiratory Tract Infection
(Common Cold) (Pediatric & Adult) 0 1 2
DISORDERS OF THE CARDIOVASCULAR SYSTEM
Angina Pectoris (Adult) 0 1 2
Congestive Heart Failure (Adult) 0 1 2
Uncomplicated Essential Hypertension
(Adult) 0 1 2
Chronic Oclusive Arterial Disease
of the Extremities (Adult) 0 1 2
Stasis Ulcer of the Lower Extremities
(Adult) 0 1 2
Pericarditis (Adult) 0 1 2
Coronary Artery Disease (Adult) 0 1 2
Innocent/Functional Murmurs (Pediatric) 0 1 2
Congenital Heart Disease (Pediatric) 0 1 2
Hypertension (Pediatric) 0 1 2
DISORDERS OF THE GASTROINTESTINAL SYSTEM
Aerophagis (Gaseous Distention
Syndrome (Adult) 0 1 2
Constipation (Adult) 0 1 2
Simple Diarrhea (Adult) 0 1 2
Functional Bowel Disease
(Irritable Bowel Syndrome)(Adult) 0 1 2
Acute Gastroenteritis (Pediatric) 0 1 2
Hiatal Hernia with Esophagitis (Adult) 0 1 2
Uncomplicated Duodenal 0 1 2
Peptic Ulcer Disease (Adult) 0 1 2
Hemorrhoids (Piles) (Adult) 0 1 2
Appendicitis (Pediatric & Adult) 0 1 2
Cholecystitis (Adult) 0 1 2
Hepatitis (Adult) 0 1 2
Pyloric Stenosis (Pediatric) 0 1 2
Colic (Pediatric) 0 1 2
OBSTETRICS & GYNECOLOGY
Guidelines for Managing the
Obstetric Patient 0 1 2
Nausea & Vomiting During Pregnance 0 1 2
Candidal Vaginitis (Adult) 0 1 2
Abnormal Papnicolaou Smear Findings
in an Asymptomatic Patient (Adult) 0 1 2
Trichomonal Vaginitis (Adult) 0 1 2
Nonspecific or Bacterial Vaginitis (Adult)
Primary Dysmenorrhea 0 1 2
Bartholin’s Duct Abcess & Cyst 0 1 2
Family Planning Methods of Birth
Control 0 1 2
Menopause 0 1 2
Pregnancy: Diagnosis & Referral 0 1 2
Pain Relief in the Active Phase of Labor 0 1 2
Intrapartum Medications 0 1 2
Medications in the Third Stage 0 1 2
Dysfunctional Uterine Bleeding 0 1 2
Improper Involution, Post-Partum 0 1 2
Medications in the Post-Partum Period 0 1 2
Rh Blood Factor 0 1 2
Mastitis 0 1 2
Secondary Amenorrhea 0 1 2
Atrophic Vaginitis (Adult) 0 1 2
Premenstrual Syndrome 0 1 2
Fibrocystic Breast Disease 0 1 2
Prenatal Care 0 1 2
Fetal Well-Being 0 1 2
Preparation for Childbirth 0 1 2
Knowledge of Puerperium 0 1 2
PARASITIC INFESTATIONS
Ascariasis (Pediatric & Adult) 0 1 2
Pediculosis (Pediatric & Adult) 0 1 2
Pinworms (Pediatric & Adult) 0 1 2
Miscellaneous Infections
Measles (Pediatric & Adult) 0 1 2
Infectious Mononucleosis
(Pediatric & Adult) 0 1 2
Mumps (Pediatric & Adult) 0 1 2
Roseola Infantum (Exanthema Subitum)
(Pediatric) 0 1 2
Varicella (Chickenpox) (Pediatric & Adult) 0 1 2
DISORDERS OF THE ENDOCRINE SYSTEM
Diabetes Mellitus Type 1 0 1 2
DM Type II (Adult) 0 1 2
Hypoglycemia (Adult) 0 1 2
Hypothyroidism (Adult) 0 1 2
Graves Disease (Adult) 0 1 2
Cushing’s Syndrome (Adult) 0 1 2
Addison’s Disease (Adult) 0 1 2
Juvenile Diabetes (Pediatric) 0 1 2
DISORDERS OF THE GENITOURINARY SYSTEM
Cystitis (Adult) 0 1 2
Acute Pyelonephritis (Adult) 0 1 2
Enuresis (Pediatric) 0 1 2
Syphillis (Adult) 0 1 2
Urinary Tract Infection (Pediatric) 0 1 2
Primary Gonococcal Infections (Adult) 0 1 2
Nonspecific Urethritis (Nongonococcal
Urethritis (Adult) 0 1 2
Acute Prostatitis (Adult) 0 1 2
Chronic Prostatitis (Adult) 0 1 2
Benign Prostatic Hypertrophy (Adult) 0 1 2
Vulvovaginitis (Pediatric) 0 1 2
Chlamydiosis (Adult) 0 1 2
Condyloma Acuminatum (Adult) 0 1 2
Herpes Genitalis (Adult) 0 1 2
Cryptorchidism (Pediatric) 0 1 2
Hypospadias (Pediatric) 0 1 2
Hydrocele (Pediatric) 0 1 2
DISORDERS OF THE MUSCULOSKELETAL SYSTEM
Minor Ankle Sprain (Pediatric & Adult) 0 1 2
Minor Strains & Sprains (Pediatric & Adult) 0 1 2
Musculoskeletal Pain (Adult) 0 1 2
Lumbarsacral Strain (Adult) 0 1 2
Nonspecific Muscoloskeletal Pain (Adult) 0 1 2
Osteoarthritis (Adult) 0 1 2
Collateral Ligament Knee Sprain (Adult) 0 1 2
Gout (Adult) 0 1 2
Pseudogout (Adult) 0 1 2
Osteoporosis (Adult) 0 1 2
Rheumatoid Arthritis (Adult) 0 1 2
Juvenile Rheumatoid Arthritis (Adult) 0 1 2
Joint & Foot problems (Pediatric) 0 1 2
Scoliosis (Pediatric) 0 1 2
Tendinitis/Bursitis (Adult) 0 1 2
Carpal Tunnel Syndrome (Adult) 0 1 2
Osteomyelitis (Pediatric) 0 1 2
Muscular Dystrophy (Pediatric) 0 1 2
DISORDERS OF THE NERVOUS SYSTEM
Dizziness in Adults <50 years old 0 1 2
Migraine Headache (Adult) 0 1 2
Tension Headache (Adult) 0 1 2
Vasovagal Syscope (Simple Faint)
in adults <50 years old 0 1 2
Anxiety (Adult) 0 1 2
Temporal Arteritis (Adult) 0 1 2
Seizure Disorders (Pediatric) 0 1 2
Seizure Disorders (Adult) 0 1 2
Multiple Sclerosis (Adult) 0 1 2
Parkinsonism (Adult) 0 1 2
Transient Ischemic Attack (Adult) 0 1 2
Stroke (Adult) 0 1 2
Trigeminal Neuralgia (Adult) 0 1 2
Bell’s Palsy (Adult) 0 1 2
Alzheimers 0 1 2
Headaches (Pediatric) 0 1 2
Head Injury (Pediatric) 0 1 2
DISORDERS OF THE HEMATOLOGIC SYSTEM
Iron Deficiency 0 1 2
Anemia of Chronic Disease 0 1 2
Pernicious Anemia 0 1 2
Folic Acid Deficiency Anemia 0 1 2
Aplastic Anemia 0 1 2
Sickle Cell Anemia 0 1 2
Thalassemia 0 1 2
MENTAL HEALTH/PSYCHOSOCIAL DISORDERS
Anxiety 0 1 2
Depression 0 1 2
Suicide 0 1 2
Grief 0 1 2
Obesity 0 1 2
Anorexia; Bulimia 0 1 2
Substance Abuse; Drugs & Alcohol 0 1 2
DISORDERS OF THE EYE
Conjunctivitis (Pediatric & Adult) 0 1 2
Hordeolum (Stye) (Pediatric & Adult) 0 1 2
Chalazion 0 1 2
Strabismus (Pediatric) 0 1 2
TECHNICAL SKLLS
Starting & Maintaining IV’s 0 1 2
Casting & Splinting 0 1 2
Suturing 0 1 2
Ingrown Toenail Removal 0 1 2
Cell Biopsy 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn (0-30 days) B= Infant (30 days-1 yr) C= Toddler (1-3 yrs) D=Preschool (4-5 yrs) E= School Age (6-12 yrs)
F=Adolescent (13-18 yrs) G= Young Adult (19-39 yrs) H= Middle Adult (40-64 yrs) I = Older Adult (65+ yrs)
A
B
C
D
E
F
G
H
I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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By checking this box I understand that this is my electronic signature and all the information is correct and true.