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

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
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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

The National Center for Acupuncture Safety and Integrity (NCASI) will contact you if we have additional questions.