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 pneumothorax (an accumulation of air in the space between the lung and the chest wall [pleural space], causing the lung to collapse) that he suffered after a physical therapist punctured his right lung with an acupuncture needle. (Photo: @TorinWallace)

 

Dry Needling Adverse Event Reporting System Form

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

Section A: Patient Information
Confidentiality: Your identity is held in strict confidence by NCASI, unless you authorize otherwise, and is protected to the fullest extent of the law.
Patient Name: *
Patient Name:
Street Address: *
Street Address:
Telephone Number: *
Telephone Number:
Date of Birth: *
Date of Birth:
Sex: *
Date of Dry Needling: *
Date of Dry Needling:
Date Adverse Event Started/Occurred: *
Date Adverse Event Started/Occurred:
Today’s Date: *
Today’s Date:
May we disclose your identity to the public?: *
Section B: Reporter Information
(If different from Patient Information)
Reporter Name:
Reporter Name:
Street Address:
Street Address:
Telephone Number:
Telephone Number:
Relation to Patient:
Section C: Dry Needling Provider Information
Dry Needling Provider Name: *
Dry Needling Provider Name:
Street Address:
Street Address:
Telephone Number:
Telephone Number:
Occupation: *
Section D: Adverse Event(s) Information
Adverse Event Type: *
(Check all that apply)
(Include as many details as possible)
(Include dates)
Outcome(s) of the Adverse Event(s): *
(Check all that apply)