Dry Needling Treatment and Consent Log

Clinical form to document dry needling trigger point treatment details, informed consent, needle insertion sites, patient response, and post-treatment adverse event screening.

Session Details

• Treatment date
• Provider name
• Clinic location
• Body region treated
• If other, specify body region

Informed Consent

• Informed consent discussed before treatment
• Patient provided informed consent
• Consent method
• Risks and expected effects explained
• If other, specify risk or disclosure
• Consent notes
  Optional brief note if the patient asked questions or additional disclosure was provided. Avoid unnecessary PII.

Needling Treatment Details

• Number of needles used
• Needle insertion sites
  List the anatomical sites treated. Use concise clinical terms and avoid unnecessary identifiers.
• Technique notes
  Optional brief note on trigger point response, needle retention time, or other clinically relevant observations.
• Patient tolerance during treatment

Post-Treatment Response and Adverse Event Screening

• Immediate patient response
• Post-treatment adverse event screening completed
• Any adverse events or complications observed
• Adverse event types
• If other, describe adverse event
• Follow-up actions or patient instructions
  Document any monitoring, education, referral, or escalation provided after treatment.