Please complete the form below to schedule a free consultation

  • Hair Tissue mineral analysis

  • Chronic Disease Management

  • Nutritional Medicine

  • Chiropractic Therapy 

  • Detoxification Protocols

Homeopathic and chiropractic consultations are facilitated with a complete assessment of an individual's mental, emotional, and physical state of health. We handle your privacy very seriously.

We will be in touch

After evaluating your medical history and current condition, we will reach out to you to schedule your complimentary consultation with Dr. Robert Selig to find out if our services are right for you

Get treated with a custom care plan

Once accepted as a patient, you may be asked to complete a Hair Tissue Mineral Analysis to reveal any mineral deficiencies and heavy metal toxicities.

This test is crucial to living a life free of chronic illnesses and hospital-visits.

You will be given a custom care plan tailored to your own bio-individuality based on nutritional medicine and detoxification protocols. 

*We accept local patients at our Chicago office and work with patients long distance over the phone, email, and video chat. 


Is this application for you or a family member? *
Name of person requesting treatment *
Name of person requesting treatment
Gender *
Phone *
Phone
Birthdate *
Birthdate
It is important to fully assess your background from birth.
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? *