Immune Health for Seniors HPx Inclusion/Exclusion/Intake Form

One form per registrant. We estimate it will take you 10 min per registrant to complete this form.


Immune health is maintained through socialization with all age groups. By activating immune system memory with HPx, the role of the elders in family settings groups is fully supported.


This program is specifically designed to strengthen immune function and activate immune system memory. HPx dosing gently stimulates immune response and induces a mild adaptation process, which in turn strengthens and activates healthy immune function and coherence.

This program is designed for individuals without extensive pathologies, Immune system collapse, or multiple medications who want to maintain their health within their extended famliy.

If three or more interventions or conditions bellow are selected, constitutional homeopathic care prior to commencing the Healthy Biome HPx Program is recommended. HPx is not intended to be used for treatment of pre-existing conditions but to reduce potential conditions from developing. This inclusion/exclusion document will also be used to analyze remedy responses and health outcomes from program participation.


All Personal Health Information (PHI) will be held in confidence within the Patron Portal and not associated with any data entered. Non-personal Health Information (non-PHI) will be used for analysis purposes.


All information will be held in confidence in the Patron Portal and not be made available to any private, public, or government entity unless there is cause for concern of self-harm or harm of others where it is required by law to report.







Inclusion/Exclusion process

Interventions or conditions Yes
No		 Talk with your practitio ner before proceeding. Constitutional homeopathic care is be needed before proceeding
Cancer Consult your practitioner
High Blood pressure Consult your practitioner
Diabetes Consult your practitioner
Inflammatory bowel disease Consult your practitioner
Autoimmune disease Consult your practitioner
Thyroid disease Consult your practitioner
High Cholesterol Consult your practitioner
Depression Consult your practitioner
Neurological conditions Consult your practitioner
Arthritis Consult your practitioner
Other Consult your practitioner
Medication 1-3 medications
4-7 medications Consult your practitioner
8 or more medications
Antibiotics History of no antibiotics
History of less than 5 rounds of Antibiotics
History of 6-10 rounds of antibiotics Consult your practitioner
More than 11 rounds of Antibiotics Consult your practitioner
Antipyretics or NSAIDS Never
Once a month Consult your practitioner
More than once a month Consult your practitioner
Pre-existing Conditions Asthma Consult your practitioner
Eczema Consult your practitioner
Allergies Consult your practitioner
Repeated illness Consult your practitioner
Developmental delays Consult your practitioner
Behavioral difficulties Consult your practitioner
Atypical neurological development Consult your practitioner

Please proceed to Intake and checkout

3 or more X :
Thank you for considering the Healthy Biome HPx. At this time, we recommend a full health intake with your HPx Practitioner and constitutional homeopathic care to address some of your underlaying conditions more thoroughly before proceeding with the Healthy Biome HPx Protocol. Once stabilized in health then re-register.

Intake
A. File number B. Date
C. HP Supervisor D. Name of Registrant
E. Sex M F DOB
F. Age at time at registration: Years ,Months
Check all that apply.

  1. Healthy
  2. History of
    • Cancer
    • Autoimmune disease
  3. Has the Individual has been exposed to or developed any of the following diseases and the dates prior to undertaking the program?
    • Cancer
    • Chickenpox
    • Whooping cough
    • Influenza
    • Mono
    • Cytomegalovirus
  4. Dates developed
  5. Severity and duration of disease(s) as checked above
    • Mild expression (few symptoms lasted 1-2 days
    • Medium expression (more systemic lasting 3-5 days, in bed some of the time, could address with home remedies)
    • Intense expression (full system disease expression, needing additional medical care including homeopathic or allopathic medicine)
    • Severe expression (Emergency room and hospitalization, life support)
  6. List of previous vaccinations if any, number of doses dates
    • List
    1. Number of doses
    2. Dates
    3. Repeat
  7. List number of times of antibiotics
  8. List number of times for antipyretics
  9. List number of times for antihistamines
  10. List other medications currently taking
  11. Seasonal allergies
    • Which allergy
  12. Food allergies
    • Which food
  13. Asthma
    • Frequency 0, 1, 2, 3, 4
    • Intensity i, ii, iii, iv
  14. Eczema
    • Frequency 0, 1, 2, 3, 4
    • Intensity i, ii, iii, iv
  15. Other diseases
    • Thyroid disease
    • High Cholesterol
    • Depression
    • Neurological conditions
    • Arthritis

Separate Data Sheet


  • MYMOP2
    1. File number:
    2. Today’s Date:
    3. Practitioner:

      4. While HPx Programs are not intended to treat pre-existing conditions, it may be that after completing such a course of remedies health may improve. As such as there may be some condition you are hoping to address through this HPx program please complete the following.
      Choose one or two symptoms (physical or mental) which bother you the most. Write them on the lines. Now consider how bad each symptom is, over the last week, and score it by circling your chosen number.

      As good as it could be, 6 as worse as it could be.


    4. Symptom one
        5. a. Rate: 0, 1, 2, 3, 4, 5, 6
    5. Symptom two
        6. a. Rate: 0, 1, 2, 3, 4, 5, 6

      Now choose one activity (physical, social, or mental that is important to you, and that one or both problems above prevent you from doing it.
    6. Activity
        7. a. Rate: 0, 1, 2, 3, 4, 5, 6
    7. How would you rate your general feeling of well being during the last week prior to commencing this HPx Program?
        8. a. Rate: 0, 1, 2, 3, 4, 5, 6
    8. How long have you had Symptom one
      • 0-4 weeks
      • 4-12 weeks
      • 3 months to 1 year
      • 1-5 years
      • Over 5 years
    9. Are you taking medication for this problem. Yes/No
      • If Yes; name of medication and dosage
        • Is cutting down this medication…
          • Not important
          • A bit important
          • Very Important
          • Not applicable
      • if No
      • Is avoiding medication for this problem
        • Not important
        • A bit important
        • Very Important
        • Not applicable


    Book your registration appointment with your practitioner here.

    • This is your file number
    • Link to Patron Portal
    • Link to d. 1. Travel HPx Exit interview.
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