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In order to provide you the best possible wellness care, please complete this form. Your privacy is important to us. This form is safe and secure. Make sure you see "Mahalo for your submission" after you click Submit, otherwise the Doctor will not have received your form!

Patient Data

Completing this form will save time and give us information to prepare for your exam. Privacy of your information is important to us. This form is HIPAA compliant and we will never share any identifying information with any third parties without your direct consent.

Illness is a synchronistic opportunity to embrace change that can lead to greater health and well being - Dr. Larry Malerba, Green Medicine.

Please rate your enthusiasm, between: 1 - not willing and 5 - very willing! If your total is less than 25, we may not be a good fit for you.

Current Complaints

Nature of injury/health concern

Vibrant health requires proper functioning of the nervous system to ensure our body cells receive the energy and stimulation needed to carry out their function. An accumulation of physical, chemical, emotional stresses can affect our body's ability to heal.

Medical History

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Through experiencing chiropractic and relieving nerve interference, over time, you may find you naturally gravitate towards more health promoting behaviors. Whether you decide to work with us short term, long term, or choose a different route, you are always welcome at Niu Health Chiropractic!

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If you do not see us in our office in person at least once each year, there will not be a doctor/patient relationship between. Instead, our communications with you will be for educational purposes only. We call these communications “Telehealth/education services”. These services we provide to you will consist of information and suggestions that are intended to assist you and your health care provider in using natural means to support your health. Telehealth services are not intended to serve as a medical diagnosis or treatment of any kind.

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