Young Adult and Collage Prep HPx Inclusion/Exclusion/Intake

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


Homeoprophylaxis (HPx) is a method of educating the immune system towards the infective process.


This HPx Program supports the individuation of the young adult through the stresses of this maturation stage. Throughout life, analytical thinking, interpretation, and direct revelation develop different aspects of the human experience. The transition to independent adulthood challenges those areas of neurological development. Healthy nutrition, rest, and a balanced academic and social life are the basics of healthy immune systems during this stage of being. HPx dosing and resultant immune responses facilitate this process while gaining the whole being benefits each immune process yields.

For optimum immunological benefits through participation in this homeoprophylaxis (HPx) Program demonstration of healthy immune function is necessary: the ability to develop a fever and recover from an infectious disease process. A history of a partial or complete vaccine schedule, or multiple uses of antibiotics or antipyretics are cause for detox and immunological balancing prior to commencing.

Accordingly, we understand that if there are three or more interventions or conditions listed below prior to commencing the Young Adult and College Prep HPx Program we are recommending you to ask your homeopath about your options. HPx is not intended to be used for treatment of pre-existing conditions.


If there are three or more interventions or conditions listed below in childhood or the teenage years, constitutional homeopathic care prior to commencing the Young Adult and College Prep HPx Program is recommended. HPx is not intended to be used for treatment of pre-existing conditions. This inclusion/exclusion document will also be used to analyze remedy responses and health outcomes from program participation. All data entered


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
Immune system function History of fevers
History of colds
History of pneumonia Consult your practitioner
History of EBV Consult your practitioner
History of auto-immune disease Consult your practitioner
Childhood Vaccinations No vaccines
Partial Childhood HPx program
Full Childhood HPx program
1-5 vaccine diseases Consult your practitioner Consider vaccine detox before
5-10 vaccine diseases Consult your practitioner Consider vaccine detox before
Antibiotics 1-4 times Consider Healthy biome program first
5 or more times Consult your practitioner
Antipyretics 1-4 times
5 or more times Consult your practitioner
Antihistamines 1-4 times
5 or more times Consult your practitioner
Medications History or current use of Contraceptives Consult your practitioner
History or current use of attention medication Consult your practitioner
History or current use of mood stabilization medication Consult your practitioner
Occasional recreational drug use
Occasional Alcohol consumption
Hospitalization Any 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
Learning disorder

Please proceed to Intake and checkout

3 or more X send to this page :
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 Health y Biome HPx Protocol. Once stabilized in health then re - register.


Intake
Initial Health Profile (one form per registrant)
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. Has the Individual has been exposed to or developed any of the following diseases and the dates prior to undertaking the program?
    • Cancer
    • Mono
    • Whooping cough
    • Tuberculosis
    • Meningitis
    • Tetanus
  2. Dates developed
  3. 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)
  4. List of previous vaccinations if any, number of doses dates
    • List
    1. Number of doses
    2. Dates
    3. Repeat
  5. List number of times of antibiotics
  6. List number of times for antipyretics
  7. List number of times for antihistamines
  8. List other medications currently taking
  9. List use and frequency of recreational drugs
    • Which allergy
    • How often
  10. List use and frequency of alcohol use
    • Type of alcohol
    • How often
  11. List hospitalizations
  12. List pre-existing conditions

    Please indicate if registrant has or does experience any of the following; how often, and to what degree of intensity.


    Frequency

    1. Never
    2. Rarely; 1-2 times /year
    3. Occasionally; 3-6 times/year
    4. Frequently; once a month
    5. Chronically; all the time
    6. Ear infections
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    7. Colds/sore throats/coughs
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    8. Seasonal allergies
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
      • Type
    9. Food allergies
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
      • Type
    10. Asthma
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    11. Eczema
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    12. Behavioral conditions
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    13. Violence
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    14. Mood swings
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    15. Fears
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    16. Learning disorders
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    17. speech delay
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    18. disturbance in cognitive function
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    19. disturbance in social function
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    20. Neurological conditions
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv
    21. Learning disorders
      • Frequency 0, 1, 2, 3, 4
      • Intensity i, ii, iii, iv

    Intensity (if at all) If never leave blank

    • almost not noticeable
    • mild symptoms
    • moderate intensity
    • severe

  • 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
      • 3.Link to d. 3. Young Adult and College Prep HPx Exit interview.
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