*All pricing is on an individual basis*

Please fill out this form and Dr. Selig will provide a complete assessment of your physical, mental, and emotional health in order to recommend a plan of action that includes specific tests, supplements, and therapies.

With over 20 years of experience helping patients suffering with chronic health problems, Dr. Selig along with his wife, Maria, work one-on-one to provide special care to each patient (local or long distance) by addressing mineral deficiencies and heavy metal toxicities to improve health at the cellular level.

Based on your evaluation, your custom plan will include hair tissue mineral analysis (and other testing if necessary), nutritional medicine, personalized diet plan, detoxification protocols, and therapeutic services to help you stay out of hospitals, doctor’s offices, and improve without the use of prescription medications.

Our most successful patients have strong self-discipline, so you must follow Dr. Robert Selig's plan 100% in order to see results. Because it takes time and sacrifice to achieve better health, we give 24/7 care by phone or text to help alleviate any pain or symptoms in order to help you heal quicker and more efficiently.

We respect your privacy and do not share your information.


Is this application for you or a family member? *
Have you had a hair tissue mineral analysis? *
Name of person requesting treatment *
Name of person requesting treatment
Gender *
Phone *
Phone
It is important to fully assess your background from birth.
Birthdate *
Birthdate
Address *
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
Whiplash
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?
Where?
Current health problems
Cardiovascular System
Endocrine System
Blood, Lymph, and Immune Systems
Respiratory System
Nervous System
Digestive System
Bowel movements *
Skin and Hair
Hair
Head
Eyes
Ears
Nose
Mouth
Throat
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?
Insomnia
Do you wake up unrefreshed?
Do you feel sleep deprived?
Nightmares | Bad dreams
Too hot or cold during sleep
Nightsweats
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? *