Pricing is on an individual basis–please fill out this form and Dr. Robert Selig will get back to you for a complete assessment of your physical, mental, and emotional state in order to recommend tests, analysis, supplements, and therapies that are right for you.

Each new patient is put on a custom care plan tailored to his or her own biochemistry and can expect to take a Hair Tissue Mineral Analysis to receive an expert analysis from Dr. Selig based on over 20 years of experience to discover what mineral deficiencies and heavy metal toxicities need to be addressed.

Dr. Robert Selig and his wife, Maria, will both work with you to manage your chronic health conditions and help you heal using nutritional medicine, detoxification protocols, and therapeutic and natural methods.

If you want to live a life free of chronic illnesses and hospital visits, we ask that you are willing to follow Dr. Robert Selig's plan 100% in order to see results. You will receive 24/7 care by phone or text to help alleviate any pain or symptoms through the healing process.

*We accept local patients at our Chicago office and work with patients long distance over the phone, email, and video chat. We respect your privacy and do not share your information.

Is this application for you or a family member? *
Name of person requesting treatment *
Name of person requesting treatment
Gender *
Phone *
Birthdate *
It is important to fully assess your background from birth.
Address *
Status *
Important for determining stress factors.
Live with *
Pets *
Furthest Education *
Please type NA if not available.
Please type NA if not available.
Work Status *
Have you served in the military? *
Alternative therapies
How would you rate your experience with alternative therapies? *
Hair Tissue Mineral Analysis, Detoxification, Nutritional Balancing and Supplementation, etc.
Have you ever been treated with homeopathic therpies? *
Have you ever been treated with chiropractic therapy? *
General Health Questions
Please list as many as you can in order of importance*
Please type NONE if you do not currently take any medications.
You took these medications for a long period of time but no longer do.
Personal Health Rating *
On a scale of 1-10, (1 = poor, 10= optimal) how would you rate your health?
How would you describe your personal health? *
How would you describe your vitality, stamina, and energy? *
Are you a warm or cold person? *
Do you prefer warm or cold drinks? *
What childhood illnesses have you had? *
Which tests have you undergone? *
Which immunizations have you received? *
Type of Illness/Operation | Date | Location
Please select all that apply to you current state of health: *
Venereal diseases (Gonorrhea, Syphilis, etc.)
Which of these do you consume or use? *
Type NONE if you are not allergic to any drugs.
Type NONE if you are not allergic to any foods or other substances.
Family Health History
Mother *
Father *
Siblings *
Grandfather (Mother's side) *
Grandmother (Mother's side) *
Grandfather (Father's side) *
Grandmother (Father's side) *
Has any blood relative had any of the following? *
General Pain Symptoms
It is very important that you answer ALL that apply to you.*
Neck Stiffness
Neck Pain and Swelling
Radiating Neck Pain
Neck Injuries
Middle back stiffness, dull pain
Herniated Disc(s)
Arthritis (Middle Back)
Middle Back Injuries
Radiating Pain (Middle Back)
Lower back stiffness, dull pain
Lower back radiating pain
Herniated discs (lower back)
Lower back arthritis
Lower back injuries
Limbs (joint pain, swelling, stiffness, tingling, numbness)
Limbs (muscle cramps)
Burning of soles of feet
Unusual redness of the palms or hands
Where? What kind?
Current health problems
Cardiovascular System
Endocrine System
Blood, Lymph, and Immune Systems
Respiratory System
Nervous System
Digestive System
Bowel movements *
Skin and Hair
Mental and emotional
Urogenital system
Male problems
Female problems
Average flow
Trouble with lactation?
Do you have nipple discharge?
Sleep and Dreams
Sleep problems and irregular sleep patterns
Sleepy during the day
Do you usually dream?
Do you remember your dreams?
Do you wake up unrefreshed?
Do you feel sleep deprived?
Nightmares | Bad dreams
Too hot or cold during sleep
Are you presently on any of these treatments? *
Weight, skin, hair, teeth, stomach, sleep, depression, etc.
These are health problems that you struggled with but no longer do.
Improvements or lack of improvement in treating your health problems, sleep, vitality, mental and emotional state, etc.
How did you hear about our services? *