Dry needling consent and screening form

Before needling

1. I have a bleeding disorder or take blood-thinning medicine Tick box · a yes is flagged to the physio
2. I am or may be pregnant Tick box · a yes is flagged to the physio
3. I have fainted with needles or injections before Tick box · a yes is flagged to the physio
4. I have diabetes or a condition that affects healing or infection Tick box · a yes is flagged to the physio
5. I am allergic to metals such as nickel Tick box · a yes is flagged to the physio
6. I have a pacemaker, implant or lymphoedema Tick box · a yes is flagged to the physio
7. Anything else we should know Written answer

Consent

1. About dry needling To read and agree to · required Dry needling uses fine, single-use, sterile needles placed into muscle to reduce pain and improve movement. Common effects are soreness or bruising for a day or two, and some people feel light-headed. Serious problems are rare. When needling over the chest wall there is a very small risk of a collapsed lung; your physiotherapist will explain how they avoid this and the symptoms to watch for. You can say no to needling, or ask to stop at any time.
2. I understand the information above and agree to dry needling Tick box · required

Signature

1. Your full name Short answer · required
2. Date Date · required

Signature

The patient signs on screen, on their phone or at the front desk, and the signed copy is kept on their file.