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Dry Needling Screening form

Please fill in the following form to the best of your ability. Filling in this form will help make our appointment more efficient.

It is important for you to consider the benefits and risks and alternatives to the acupuncture treatment offered by your health care provider and to make an informed decision about proceeding with treatment.


Dry needling involves inserting a tiny sterile monofilament needle into soft tissue with the aim to:

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  • relieve muscular tension 

  • release shortened muscle fibers 

  • and decrease trigger point activity 

 

This happens through a physiological cascade which begins with the body’s interpretation of the monofilament needle as a mechanical stimulus to signal the nervous system to release specific endogenous biochemical agents into the local soft tissue region. This in turn can help resolve pain and muscle tension, and will promote healing.

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The methodology and theory that Dry needling is based on is dissimilar to Chinese acupuncture, and is a validated medical treatment which relies on a medical diagnosis to be effective. Dry needling is a valuable and effective treatment for musculoskeletal pain.

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Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment.

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Risks: The risks associated with acupuncture include minor bleeding and bruising, temporary pain and soreness, nausea, fainting, burns, infection, shock, convulsions, pneumothorax, perforation of internal organs, and stuck or bent needles. The most serious risk with dry needling is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely require a chest X-Ray and no further treatment. The symptoms are shortness of breath may last for several days to weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include injury to a blood vessel causing a bruise, infection, and/or nerve injury.

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Alternatives: Alternatives to acupuncture treatment may include rest, exercise, other modalities or consulting other health professionals.

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Only sterile single use disposable needles will be used. All acupuncture needles are properly disposed of after each and every treatment.

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Questions or Concerns: You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the health care provider’s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your health care provider immediately of any change in your condition.

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Specific Screening Questionnaire

Please answer to the best of your ability. If unsure please ask your therapist for clarification.

Are you currently taking anticoagulants (ex: Aspirin, blood thinners)?
Are you currently taking antibiotics for an infection?
Are you pregnant?
Do you suffer from metal allergies?
Are you a diabetic or do you suffer from impaired wound healing?
Do you have Hepatitis B, C, HIV, or any other infectious disease?

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