New patient intake & Dry Needling Screening Form New Patient Intake & Dry Needling Screening Form Note: Please fill out this form the best you can as this information will guide treatment recommendations. New Patient Information: Personal Information Name * Name First First Last Last Date of Birth * Place of Birth Occupation Home Phone: Work Phone: Mobile Phone: * Email * Address * Address Address Address Subrub (if non please put N/A) Subrub (if non please put N/A) City/Town City/Town Zip/Postal Code Zip/Postal Code Emergency Contact Name * Name First First Last Last Relationship * Phone * Email General Practitioner Doctors Name Practice Name Practice Address Practice Address Practice Address Practice Address City City Province Province Zip/Postal Zip/Postal I agree Relief Point Physiotherapy can communicate relevant information with my GP: Yes No ACC Information: Do you have a current ACC claim? Yes No Please provide your ACC claim information: ACC claim # (e.g. AB12345): Date of injury: Site of injury (e.g. right elbow): Complaint & Medical Information Current complaint (How and when did it start?) Previous injuries e.g. knee sprain Injury Date plus1 Add minus1 Remove Past or current medical diagnoses Diagnoses Date plus1 Add minus1 Remove Past Treatment for Medical Problems (Hospitalisations, Injuries, Operations, Chemical Exposures, Blood Transfusions) Type of operation or illness: Location Date plus1 Add minus1 Remove Family history relevant medical/illness (cancer, heart attacks etc) Medical/illness Relationship plus1 Add minus1 Remove Have you had dry needling treatment or acupuncture before? Yes No When, frequency and for how long: For what: By who: Does it help: Dry Needling Screening What and Why? Acupuncture and dry needling are forms of treatment where very fine acupuncture needles are inserted into the tissues (pierces the skin) to create neurophysiological reactions in the body and stimulate a healing effect. Depending on the specific points chosen & technique used, this assists with pain relief, reducing inflammation, improving local immune/healing responses and relaxing muscle spasm to assist healing. Precautions & Contraindications: Your practitioner will screen for reasons why extra care needs to be taken or whether you should not have acupuncture or dry needling (precautions or contraindications). To assist with this please indicate whether you have any of the following conditions: Pregnancy: especially if history of miscarriage (tick yes if you may be or are trying to fall pregnant) Yes No Blood clotting disorders (e.g. Haemophilia) Yes No What type: Anticoagulants “blood thinners” (e.g. warafin, aspirin) Yes No What type: Steroids (corticosteroids) Yes No Artificial Implants (e.g. pacemaker, heart valves, joint replacements, cosmetic surgery) Yes No What type: Infections Yes No Where: Cancer or Malignant disease Yes No Where: Diabetes Yes No What type: Mastectomy or axillary clearance? Yes No Cardiac (Heart) conditions Yes No Immune diseases (e.g. Lupus, Rheumatoid) Yes No Disease type: Epilepsy Yes No Last seizure: Areas of Numbness or reduced feeling Yes No Where: Allergy to Metals Yes No Significant Fatigue or Drowsiness or history of fainting Yes No Hepatitis A, B or C, Aids/HIV Positive Yes No What you should know before your Dry Needling appointment Risks/Side effects Most risks are minor. These may include (but are not limited to): Bruising or bleeding Fainting Nausea Discomfit or rarely pain. Alteration of energy levels. Some people may experience either high levels of energy or may feel fatigued after acupuncture/dry needling. Very rare (less than 1 in 10,000): Infections Metal allergy Certain areas have risk of Pneumothorax (collapsed lung)(less than 1 in 70,000 0 –– 1.27 million) Preparation for treatment: Have a meal or light snack before attending for treatment. It is possible that acupuncture/dry needling may affect blood sugar levels. This is particularly important if you are diabetic. Technique: You will be positioned comfortably usually in a lying position. Sterile needles (single use) will then be inserted. A sharp feeling is usually felt. Depending on the technique – the needles may be manipulated. For dry needling some techniques involve manipulating the needle until a jump or twitch is achieved in the muscle. This helps release trigger points in the muscles. Needles may be further manipulated during the treatment. Needles will be removed after a periods of treatment. Cautions after the Treatment: Fatigue and Drowsiness: Again ensure that before driving a vehicle you are not feeling drowsy or fatigued. If you do experience this – have a snack or drink and rest until you are safe to drive. If you suffer from fatigue or drowsiness after acupuncture ensure you inform your Practitionry prior to treatment and arrange for someone else to drive you to and from the appointment. Discomfort and minor bruising: It is normal for some people to experience mild discomfort – particularly in the first treatment or two. Some dry needling techniques typically result sin soreness for a day or two. Very minor bruising or bleeding may also happen. An ice pack can assist recovery (10-15mins – use safely: towel around icepack, remove if too cold or painful). Pneumothorax (Puncture/collapsed lung): This is extremely unlikely with appropriate needle application. However, if you do experience increasing shortness of breath following acupuncture/dry needling over the shoulders or trunk, please contact your therapist directly or attend to the nearest hospital emergency department. If you have any concerns please contact your treating Practitioner. Patient Consent: Please ensure you are familiar with our pricing before your appointment. Please also note you are required to give at least 24 hours notification of cancellation or rescheduling in order to avoid being automatically invoiced a full treatment charge and by completing this form you agree to pay this fee if not compliant. By completing this form and ticking Agree below, you agree that all information given is as accurate and complete as possible. You also consent to all assessment and treatment performed by Relief Point Physiotherapy and consent to having acupuncture/dry needling technique as part of your physiotherapy management. You have had the procedure explained to you including potential benefits and risks or side effects as detailed above. You have been given sufficient opportunity to ask any questions. * Agree Your Name: * Date * Submit If you are human, leave this field blank.
