DOCUMENT (X)

Issue no 2

Date of Issue 17/07/2017

 

ACUPUNCTURE CONSENT TO TREATMENT

 

Acupuncture is a form of therapy in which fine needles are inserted into specific parts of the body. Single use, disposable needles are always used in the clinic.

Intend benefits of treatment:

·         Reduction of pain

·         Alleviation of muscle spasm and tension

·         Facilitation of the healing process

·         Induction of local and general relaxation

·         Promotion of general wellbeing

·         Improvement of sleep pattern

 

Possible adverse effects

 

The following are known possible adverse effects (based on research evidence) associated with

Acupuncture. Your physiotherapist will discuss these with you and explain if you are at any enhanced risk.

 

·         Bleeding and bruising (3%)

·         Mild aggravation of symptoms (3%, of which 70-85% show subsequent improvement)

·         Mild pain at needle site (1%)

·         Drowsiness(1%) and Dizziness (0.6%)

·         Pain not at needle site (0.5%)

·         Nausea (0.3%) and feeling faint (0.3%)

·         Stuck or bent needle (0.1%)

·         Headaches (0.1%)

·         Allergy or infection (up to 0.2%)

·         Pneumothorax (less than 2 per 1 million                                                   

Acupuncture is generally very safe although if you experience any of the above, or notice anything unusual about your health following treatment, then you should notify your physiotherapist or GP.

Have you had any acupuncture previously?     Yes/No

If yes, did you have any adverse reactions?   Yes/No

Are you pregnant or trying to conceive?        Yes/No

Have you eaten within the last 2 hours?        Yes/No

I am not suffering from any of the following, or have (or had) any of the following conditions:-

·         Diabetes

·         Cancer or Radiotherapy

·         Chronic kidney disease

·         Hypertension or hypotension

·         Heart condition including damaged heart valves

·         On anti-coagulation therapy

·         Blood clotting or bleeding disorders e.g. DVT, PE or Haemophilia

·         Pacemaker/electrical implant

·         HIV, Hepatitis or AIDS

·         Immuno-compromise condition

·         Allergy to metal solutions

·         Poor skin condition/anaesthesia

·         Implants- as a result of surgery/artificial joints

·         Epilepsy/fits or inability to stay still

·         Psychological disorder or needle phobia

·         Prone to fainting (not an absolute contra-indication but may be considered)

·         Conditions requiring surgical procedures (which may alter the anatomical landmarks used by the Acupuncturist to accurately identify the points for treatment)

·         Conditions requiring concurrent drug treatment such as oral antihistamines or oral steroids which often have a depressant effect of the brain

·         Systematic (generalised) inflammatory conditions

 

I understand that some of the above are not absolute contra-indications to treatment, but that if the therapist felt that it was applicable to try acupuncture, written authorisation from the patient ‘s GP would be necessary before the procedure can continue.

 

I have been advised that drowsiness may occur following acupuncture and it is, therefore, wise not to drive immediately following acupuncture.

 

I confirm that I have read and understood the information on this form and have had the opportunity to ask questions. I confirm I have received a leaflet explaining acupuncture to me. I understand what the treatment is likely to involve, the intended benefits and possible adverse effects, therefore I give consent to having acupuncture treatment.

 

I understand I can withdraw from treatment at any time. I agree not to disturb the needles during the treatment period and will ask for assistance if I have any concern. I know of no reason why I should not have acupuncture treatment.

 

IF YOU GIVE BLOOD, PLEASE LET YOUR PHYSIOTHERAPIST KNOW.

 

PATIENT NAME……………………………………………………………………………..

 

SIGNED ………………………………………………………………………………..DATE………………………………………..

ANYONE UNDER 16 YEARS OF AGE SHOULD BE ACCOMPANIED BY THEIR PARENT OR GUARDIAN WHO WILL BE REQUIRED TO SIGN THE CONSENT FORM

 

Moira D’Arcy

Practice Principal

 

Acupuncture consent form

 
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