1. Patient Name *

First Name

Last Name

2. Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

3. Telephone Number *

(###)

###

####

5. Date of Birth *

MM

DD

YYYY

6. Sex *

Male

Female

1. Reporter Name

First Name

Last Name

2. Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

3. Telephone Number

(###)

###

####

5. Relation to Patient

Parent

Guardian

Spouse

Attorney

Other (Specify below)

1. Dry Needling Provider Name *

First Name

Last Name

2. Occupation *

Physical Therapist

Chiropractor

Athletic Trainer

Occupational Therapist

Other (Specify below)

2. Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

3. Telephone Number *

(###)

###

####

1. Date of Dry Needling *

MM

DD

YYYY

2. Outcome(s) of the Dry Needling Adverse Event *

(Check all that apply)

Doctor Office/Clinic Visit(s)

Emergency Department Visit(s) (Include name of emergency department below)

Hospitalization (Include number of days of hospitalization and name of hospital below)

Life-Threatening (Immediate risk of death from the adverse event)

Disability (Significant, Persistent, or Permanent)

Permanent Impairment of a Body Function or Permanent Damage to a Body Structure

Necessitated Medical or Surgical Intervention to Preclude Permanent Impairment of a Body Function or Permanent Damage to a Body Structure

Death (Include date of death below) (MM/DD/YYYY)

None of the Above

4. Date of This Report *

MM

DD

YYYY