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Dry Needling informed consent form
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Dry Needling Consent Form
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I have a fear of needles
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I have a genetic bleeding disorder
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Please specify
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I have a history of a blood disorder that can be transmitted to another person
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Please specify
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I am regularly taking blood thinning (anti-coagulation) medication
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Please specify
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I am regularly taking pain relievers
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Please specify
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CONSENT TO TREAT A MINOR CHILD
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I hereby give authorization and consent to this Chiropractic office, and whomever they may designate as assistants, to administe
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_____________(name of child). This consent will continue in effect until further notice.
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I further give consent to administer Chiropractic and/or Physical Therapy care as deemed necessary to my
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_____________(name of child)
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with or without my presence during routine office visits
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AUTHORIZATION TO DISCUSS PATIENT CARE
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Authorization to discuss care
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I WISH LIST
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I WISH.... NAME 3 THINGS THAT YOU WISH YOU COULD DO WITHOUT PAIN
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1._____________
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2._____________
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3._____________
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Please read the questions carefully and answer each one honestly by selecting yes or no
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1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doct
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2. Do you feel pain in your chest when you do physical activity?
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3. In the past month, have you had chest pain when you were not doing physical activity?
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4. Do you lose your balance because of dizziness or do you ever lose consciousness?
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5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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6. Is your doctor currently prescribing drugs (i.e., water pills) for your blood pressure or heart condition?
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7. Do you know of any other reason why you should not do physical activity?
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