General information


*Who recommended our clinic to you?

Authorization for divulgation of personal information

*Do you authorize the chiropractors of the Clinique Chiropratique St-Sauveur to transmit, as needed, information from your client file to:

Cancellation fee consent

Physical examination consent

Reason for visit

What are your major complaints? (by order of importance)

*Do you take any medications?

Do you take any natural health products / supplements?





At work

Primary position

Repetitive tasks


Sleeping position

Pain that wakes you up

Have you had any of the following conditions:


Thyroid gland dysfunction

Anemia or blood disorders

Arthritis or rhumatism

Cancer, cyst or tumour

Jaw pain or cracking

Depression/anxiety/significant stress

Diabetes or hypoglycemia

Easy bruising

Numbness or tingling

Sprain, tendinitis or bursitis

Epilepsy or seizures

Dizzyness or vertigo




Chills or fever

High or low blood pression

Urinary or fecal incontinence


Skin disease

Neck pain

Back pain

Headaches or migraines


Edema (swelling)

Recent weight loss or gain

Heart burn / gastric reflux

Blood in urine or feces

Eye or ears problems

Heart problems

Breathing difficulties

Digestion difficulties

Hormone imbalance

Kidney difficulties, kidney stones

Prostate difficulties

Frequent urination

Section reserved for females

Painful menstruations

Menopausal symptoms

Are you pregnant?



Pelvis or low back pain

Family history. Do numerous members of your family suffer or have suffered from any of the following:

*Have you ever had a traumatic accident (work, sport, motor vehicle, etc.):

*Have you had any surgeries

Consent to Chiropractic Treatment

It is important for you to consider the benefits, risks and alternatives to the treatment options proposed by your chiropractor, to be aware of the procedure for the proposed treatments and to be fully informed before beginning treatment, in accordance with Section 43 of the Code of Ethics for Chiropractors. Chiropractic treatment may include adjustment, manipulation and mobilization of the spine and other body joints, soft tissue (muscle and other supporting tissue) release techniques and other treatment modalities such as electrotherapy or laser therapy and exercise prescription.


Chiropractic treatment has been shown to be effective for a variety of problems affecting the neck, back and other areas of the body that are caused by dysfunction of nerves, muscles, joints and other related tissues. The treatment provided by your chiropractor can relieve pain, including headaches, numbness or other abnormal sensations, muscle stiffness and spasms. Chiropractic treatment can also increase mobility, improve joint, muscle and nervous system function, and reduce or eliminate the need for medication or surgery.


The risks associated with chiropractic treatment vary depending on each patient's condition, the part of the body being treated and the type of treatment provided.

The risks include:

  • Temporary worsening of symptoms - Generally, any increase in pre-existing symptoms, pain or stiffness will only last a few hours to a few days.
  • Skin irritation or burn - Skin irritation or burns may result from the use of some electrotherapy or laser equipment. A skin irritation should disappear quickly. A burn may leave a permanent scar.
  • Muscle or ligament elongation - Normally, a muscle or ligament strain will heal in a few days or weeks with some rest, protection of the affected area and other minor care.
  • Rib fracture - A fractured rib is painful and can limit your activities for a while. This problem usually heals on its own within a few weeks, without the need for treatment or surgery.
  • Injury or aggravation of a disc problem - Over time, the discs in the spine can become degenerated or damaged. Degeneration is caused by aging, while damage can result from common everyday actions, such as bending or lifting. Patients who already have a damaged or degenerating disc may not have symptoms. They may not even know they have a disc problem. They may not even know that their condition is getting worse because their back or neck problems are not very common. Chiropractic treatment should not cause damage to a disc that is not damaged or affected by degeneration. However, the treatment could aggravate a pre-existing problem, just like any other activity of daily life. The consequences of a disc injury or worsening of a pre-existing problem will vary for each patient. In the most severe cases, patient symptoms may include loss of mobility in the back or neck, numbness in the legs or arms, impaired bowel or bladder function, or impaired leg or arm mobility. Surgery may be required.
  • Cerebral vascular accident (CVA) - Although current medical and scientific evidence does not support the notion that chiropractic treatment can cause artery damage or stroke, there have been rare cases where chiropractic treatment has been associated with stroke. However, these cases may be explained by the presence of an already damaged artery or the fact that the patient was progressing toward a stroke at the time he or she saw a chiropractor. Several activities of daily living involving common neck movements have also been associated with strokes. These result from a damaged artery in the neck or a clot already in the artery that breaks loose and travels up to the brain. Blood reaches the brain through two groups of arteries that run through the neck. Aging, disease or injury can weaken or damage these arteries. A blood clot can form in a damaged artery. The clot, or part of it, can break away from the artery wall and travel up to the brain, where it can interrupt blood flow and cause a stroke. The consequences of a stroke can be very serious, including significant impairment of vision, language, balance and brain function, as well as paralysis or death.

Alternative choices

Alternative choices to chiropractic treatment may include consultation with other health care professionals. Your chiropractor may also recommend a period of rest without treatment or exercises with or without treatment.

Questions or concerns

We encourage you to ask questions at any time about your evaluation and treatment. Do not hesitate to mention to your chiropractor any concerns you may have. If you feel uncomfortable, you can stop treatment at any time.

Your health concerns you, be responsible for it.

Notify your chiropractor immediately of any changes in your health.

Please read the consent form carefully as you will have to sign it at your first appointment.