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Welcome to Centre-Ville Chiropratique

Please take a few moments to fill out our online form before your first visit. All information will be kept confidential.

ATTENTION: This form is not a booking form. You must complete this form AND book an appointment online or by calling 514-954-1099.

    Personal information

    Date (obligatory)

    Gender (obligatory)

    First name (obligatory)

    Last name (obligatory)

    Address (obligatory)

    City (obligatory)

    Zip code (obligatory)

     

    We need at least one phone number.
    Your cell phone number will be used to find your account
    or receive appointment reminder text messages.

    Email (obligatory)

    Cell phone (obligatory)

    Home phone

    Work phone

    Phone extension

    Date of birth (obligatory)

    Age

     

    How did you hear about our clinic?



    Other

    Job/Profession (obligatory)

    Employer

     

    Reason(s) for consultation

    Reasons for the consultation (obligatory)

    How long has this problem been present? (obligatory)

    Please indicate the intensity of your pain (0=No pain, 10+Extreme pain) (obligatory)

    Have you ever received treatment for this problem? (obligatory)

    How did this problem occur? (obligatory)

    What improves your condition? (obligatory)

    What makes it worse? (obligatory)

    The condition (obligatory)

    Is the condition (obligatory)

     

    Describe your pain (obligatory)

    Health condition

    Are you taking any medications? (obligatory)

    Have you been hospitalized? (obligatory)

    Have you had in the past or do you currently have any problems with:

    Allergy
    Thyroid gland disease
    Anemia or blood disease
    Arthritis or rheumatism
    Cancer, cyst or tumor
    Cracking or pain in the jaw
    Depression or anxiety
    Diabetes or hypoglycemia
    Bruises (easy bruising)
    Numbness
    Sprain, tendonitis or bursitis
    Epilepsy or convulsions
    Dizziness or vertigo
    Fatigue
    Fracture
    Chills or fever
    High or low blood pressure
    Urinary or fecal incontinence

    Insomnia
    Skin disease
    Neck pain
    Back pain
    Headaches or migraines
    Nausea
    Oedema (swelling)
    Recent weight loss or gain
    Gastric Reflux
    Eye or ear problems
    Disorders of the heart
    Respiratory problems
    Digestive disorders
    Hormonal disorders
    Kidney problems, kidney stones
    Blood in the urine or stool
    Frequent urination
    Prostate disorders

     

    Section reserved for women

    Are you pregnant?
    What is your expected delivery date?

     

    Lifestyle habits

    Do you smoke? (obligatory)

    What is your sleeping position? (obligatory)

    Are you physically active?

    Adequate work station?

    What is the quality of your diet?(obligatory)

    Quantity of alcohol per week

    Quantity of coffee per day

    Number of glasses of water per day

    Stress level (obligatory)

    How important is your health to you? (0=not at all, 10+priority)

    Communication by email and sms

    Consents (obligatory)

    Accuracy of information (obligatory)

    Authorization for evaluation (obligatory)

    Privacy and Sharing of Personal Information (obligatory)
    I authorize the clinic and its associated professionals to collect my personal and medical information as indicated above, to communicate this information among the various professionals of the clinic, to communicate with my family physician and/or referring physician to discuss my treatments and to consult my Quebec Health Record (DSQ) if necessary. I also understand that my personal and medical information is confidential and will only be shared with third parties with my permission.

    Cancellation Policy (obligatory)

    A late cancellation or missed appointment leaves a gap in the professional's schedule that could have been filled by another patient. Therefore, we require 24 hours notice for all cancellations or changes to appointments, otherwise, we will charge a cancellation or missed appointment fee to all patients who do not give a minimum of 24 hours notice.