This is a general health questionnaire designed to help your HP Supervisor assess and keep record of your immune status prior to taking an immunologically stimulating agent.

Adults and children whose immune systems are functioning and developing normally are eligible to participate.

Those whose health history demonstrates an immunological disturbance may need prior constitutional homeopathy before participating in any HP program as recommended by your HP Supervisor.

You, your HP Supervisor, and FHCi will all receive a copy of this form once completed.

Please complete a separate form for each person you wish to register.

The information you share on this form is confidential, and will only be used to determine the status of your immune system for the purposes of this program.

REV. 3/19/21