This government document is issued by Podiatric Medical Examiners Board (0140) for use in Oklahoma
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https://www.google.com/url?client=internal-element-cse&cx=011016168438751653346:hresk_9zb-o&q=https://www.okmedicalboard.org/physical_therapists/download/524/PT_Form_5_INDIVIDUAL.pdf&sa=U&ved=2ahUKEwiGk7L_r8eUAxW6NPsDHS79Mx0QFnoECAQQAQ&usg=AOvVaw3SwLIGYQbsZxcjoEPL_wYv