Travel HPx Program Inclusion/exclusion/intake form

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

For individuals wishing to travel to foreign countries. Particularly those with tropical, insect borne, and food borne diseases.


The greatest risk for disease in foreign and remote countries is exposure to different bacteria or insect borne disease. The introduction of disease nosodes from foreign environments builds the body’s natural adaptation skills necessary for those environments to expand one’s immune capacity and world view.

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
History of previous disease Hepatitis A
Malaria
Dengue Fever
Thypoid
Inflammatory bowel disease
Yellow Fever
Pre-existing Conditions Asthama 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.

Do you have a past history of:


  1. Hepatitis A
    • If so when?
    • How treated?
  2. Hep A vaccination
    • If so When?
  3. Malaria
    • If so when?
    • How treated?
  4. Anti-malaria medication
    • If so when?
  5. Dengue
    • If so when?
    • How treated?
  6. Dengue fever Vaccine
    • If so when?
  7. Typhoid
    • If so when?
    • How treated?
  8. Typhoid vaccination
    • If so when?
  9. Inflammatory bowel disease
    • If so when?
    • How treated?
  10. Yellow fever
    • If so when?
    • How treated?
  11. Yellow fever vaccine
    • If so when?
  12. Other health condition?
    • list

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. 4. Travel HPx Exit interview.
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