torin-yater-wallace.jpeg

In this November 30, 2013 photo, 17-year-old professional freeskier Torin Yater-Wallace gives the thumbs-down sign from his hospital bed at St. Anthony Summit Medical Center in Frisco, Colorado, while recovering from surgery for a traumatic pneumothorax (an accumulation of air in the pleural cavity resulting from blunt or penetrating chest injury and causing lung collapse) that he suffered after a physical therapist punctured his right lung with an acupuncture needle. (Photo: @TorinWallace)

 
 
 

Dry Needling Adverse Event Reporting System (DNAERS) Form

To report a serious adverse event caused by an unqualified practitioner of acupuncture, such as a physical therapist, performing dry needling, use the Dry Needling Adverse Event Reporting System (DNAERS) form. The National Center for Acupuncture Safety and Integrity (NCASI) will use the information as part of our legislative and administrative advocacy work.

Note: Fields marked with an asterisk (*) are required.

Section I: Patient Information
Patient Name *
Patient Name
Street Address *
Street Address
Telephone Number *
Telephone Number
Date of Birth *
Date of Birth
Sex *
Section II: Reporter Information
(If different from Patient Information)
Reporter Name
Reporter Name
Street Address
Street Address
Telephone Number
Telephone Number
Relation to Patient
Section III-A: Dry Needling Provider Information
Dry Needling Provider Name *
Dry Needling Provider Name
Occupation *
Section III-B: Dry Needling Facility/Clinic Information
Street Address *
Street Address
Telephone Number *
Telephone Number
http://
Section IV: Dry Needling Adverse Event Information
Date of Dry Needling *
Date of Dry Needling
Outcome(s) of the Dry Needling Adverse Event *
(Check all that apply)
(Include as many details as possible)
Date of This Report *
Date of This Report

We will contact you if we have additional questions.