HP Inclusion Survey - Edi Pfeiffer

FHCi Homeoprophylaxis Program 2019
Initial evaluation: Inclusion and Exclusion form

Homeoprophylaxis (HP) is a method of educating the immune system towards the infective process. Free and Healthy Children International (FHCi, a non-profit charitable organization) was established to oversee research of, access to, and public education regarding the method of homeoprophylaxis.
You have contacted one of our certified HP Supervisors to partake in this HP program for yourself or your child(ren). In order to determine if suitability for participation in the research part of this program please complete this short questionnaire, which will be used to determine immune system health.

This short survey form should take 10-15 minutes to complete and will be submitted electronically to your proposed HP Supervisor, Edi Pfeiffer. Upon receipt and review, your HP Supervisor will contact you to discuss eligibility for this program.

updated 12.5.19 mm
Your Name*
(If applying for your child, please enter his/her name)
This application is for:

MeMy childAnother adult
Applicant's Name*
(If applying for your child, please enter his/her name)
If under 5 years, applicant's age in months (if unborn, month of expected due date)
Date of Birth (or due date)*

MonthDayYear
State or Province of Residence*
Parent Info (If you are an adult applying for yourself, please include YOUR info as "Parent #1"; you may skip 'Parent #2').
Parent #1*

First NameLast Name
Parent #1 Phone Number*

Area CodePhone Number
Parent #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent #1 E-mail*
Parent #2

First NameLast Name
Parent #2 Phone Number

Area CodePhone Number
Parent #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent #2 E-mail
Parent #2 address is

The same as Parent #1Different from Parent #1

In the following section, please indicate if the applicant has experienced each syndrome, indicating frequency and intensity.
Ear Infections*
Cough, cold, sore throat*
Seasonal allergies*
Food allergies*
Asthma*
Eczema*
Mood swings*
Violence*
Fears*
Speech delay*
Disturbances in cognitive function*
Disturbances in social function*
Neurological conditions*
Please list all medications the applicant is currently taking or has taken within the past 24 months. (not vitamins or nutritional supplements)
Anything you would like to add?
Your Name*
Today's Date*

MonthDayYear
Should be Empty: