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Dry Needling Consent

What is Dry Needling?

Dry needling is a form of therapy in which fine, solid filament needles are inserted into myofascial trigger points and other connective tissues to activate a healing response to repair tissues and facilitate muscle contractions to improve motor function. It is a specific technique to target deeper tissues that is specific with longer lasting effects. Dry needling is not acupuncture or Oriental Medicine; that is, it does not have the purpose of altering the flow of energy (“Qi”) along traditional Chinese meridians for the treatment of diseases.

 In Physical Therapy, dry needling stimulates muscles, nerves, and connective tissues to positively affect mobility and function and provide pain relief. Some conditions indicated for dry needling include neck or low back pain, tension headaches, shoulder, hand, knee, or hip pain, impingement syndromes and plantar fasciitis.



What are the risks of Dry Needling?


Temporary soreness at site of insertion, bruising or bleeding at the insertion site, discomfort during treatment, and lightheadedness or dizziness after procedure. More serious although rare risk pneumothorax and occurs in less than 1 per 10,000 (less than 0.01%) treatments.

The signs and symptoms of a pneumothorax may include shortness of breath on exertion, increased breathing rate, chest pain, a dry cough, bluish discoloration of the skin, or excessive sweating. If such signs and/or symptoms occur, you should immediately contact your physical therapist or physician. Nerves or blood vessels may be damaged from dry needling, which can result in pain, numbness, or tingling; however, this is a very rare event and is usually temporary. 



●Is there anything the practitioner needs to know?


●1. Have you ever fainted or experienced a seizure?

●Yes

●No


●2. Do you have a pacemaker or any other electrical implant?

●Yes

●No


●3. Are you currently taking anticoagulants (blood-thinners e.g. aspirin, warfarin, coumadin)?

●Yes

●No


●4. Are you currently taking antibiotics for an infection?

●Yes

●No


●5. Do you have a damaged heart valve, metal prosthesis, or other risk of infection?

●Yes

●No


●6. Are you pregnant or actively trying for a pregnancy?

●Yes

●No


●7. Do you suffer from metal allergies?

●Yes

●No


●8. Are you a diabetic or do you suffer from impaired wound healing?

●Yes

●No


●9. Do you have hepatitis B, hepatitis C, HIV, or any other infectious disease?

●Yes

●No


●10. Have you eaten in the last two hours?

●Yes

●No


●Single-use, disposable needles are used in this clinic.

●STATEMENT OF CONSENT I confirm that I have read and understand the above information, and I consent to having dry needling treatments. I understand that I can refuse treatment at any time.


●I consent

●I do not consent


●Type your full name and date of completion of form

●


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