• Homeopathic Flu-season Preparation: Immune Boost Program

    CONFIDENTIAL Participant screening and Permission form

    This short survey form should take 5-10 minutes to complete and will be submitted electronically to our Program Supervisors. Upon receipt and review, your chosen HP Supervisor will contact you by phone or email. If you are eligible to participate, you can expect to start the program within 7-10 days of payment processing.

    Homeoprophylaxis (HP) is a method of immune system 'education' that has been shown to be effective in preventing infectious disease. Program participants will utilize a homeopathic preparation to boost and pre-program their immune systems for possible exposure to a seasonal influenza virus. 

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

  • How did you find out about this program?
  • I am completing this form for*

  • If you are completing this form for someone else,

    please answer all questions "as if" you were that

    person. Thank you!!

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  • Your Age*
  • I am currently receiving homeopathic care from
  • If accepted into this program, I would like to work with *

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

    Those whose health history demonstrates an immunological disturbance will not be eligible for this program. For those individuals, we may recommend a mimimum 6-month course of constitutional homeopathy before participating in any HP program. Please ask your homeopath or HP Supervisor about this option.

  • When was the last time you received a flu shot?*
  • Have you participated in this program or a similar HP program in the past?*
  • Have you ever had a reaction to a flu shot?*
  • Have you ever had a reaction to another shot?*
  • When was the last time you were sick with "the flu"?*
  • Do you have access to conventional or alternative medical care?*
  • Have you ever been diagnosed with any of the following conditions?*
  • Have you ever been exposed to or contracted any of the following?*
  • Have you needed medication or treatment of any of the following conditions?*

  • In the following section, please indicate if you have experienced any of these syndromes, indicating frequency and intensity.

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