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Intake Form (Checklist) for CEASE Clients
Please check anything that applies on this list along
with the dates
!

Important health and medication for child’s father and mother
before pregnancy:
Vaccinations:* (Tropics) vaccines: DTP, typhoid (typhoid fever), yellow fever, Hep A, Hep B* Cholera, rabies (rabies) or Mantoux (TB control through arm prick)* Tetanus vaccine in repeat injuries (tetanus toxoid)* Hepatitis B vaccine - for doctors, nurses, caregivers, etc. or as tropical vaccine.
* Malaria Prevention: Malarone, Lariam* Diseases that have left a lasting disruption: Lyme, Mono, colitis, asthma, epilepsy, depression, migraines, etc. and their treatment* Drugs (antibiotics, sleeping pills, acetaminophen)* Anesthesia* Operations* Echo, CT scan, MRI* Dental treatments: eg Amalgam fillings, anesthesia* IVF (In vitro fertilization) : Clomid , Pregnil (Chorionic Gonadotropin)* Chronic medication in asthma, colitis, epilepsy or other diseases* Antihypertensives (nifedipine, .)* Use of cortisone ointment (hydrocortisone)* Antihistamines for hay fever * Medicines to prevent vomiting* Antacids: such as Maalox or Amphojel (aluminum hydroxide)* Iron for anemia * Vaginal Tablets for fungal infection * Highly emotional events sometimes sedative drugs
* Alcohol
* Drugs
* Vinyl in the bedroom or other rooms in the house
* Cooking in aluminum pans
* Frequent travel by plane (or work as a flight attendant or pilot)
* High amounts of mobile phone usage
* Wireless antenna (WiFi) wireless internet at home.
Important health and medication for the child’s mother during the
pregnancy and unborn child
:
Vaccinations:* (Tropics) vaccines: DTP, typhoid (typhoid fever), yellow fever, Hep A, Hep B* Cholera, rabies (rabies) or Mantoux (TB control through arm prick)* Tetanus vaccine in repeat injuries (tetanus toxoid)* Hepatitis B vaccine - for doctors, nurses, caregivers, etc. or as tropical vaccine.
* Malaria Prevention: Malarone, Lariam* Diseases that a lasting disruption left: Pfeiffer, Lyme, colitis, asthma, epilepsy, depression, migraines, etc. And their treatment. * Drugs (antibiotics, sleeping pills, acetaminophen)* Anesthesia* Operations* Amniocentesis* Echo, CT scan, MRI* Dental treatments: i.e.-Amalgam fillings, anesthesia* Injection between 28-30 weeks of anti-Rhesus (D)-globulin (or rhedquin rhophylac)* Chronic medication in asthma, colitis, epilepsy or other diseases* Antihypertensives (nifedipine, .)* Use of cortisone ointment (hydrocortisone) * Antihistamines for hay fever (Aeries)
* Medicines to prevent vomiting
* Antacids: Maalox, Gaviscon and Antagel (alumina)
* Iron for anemia (or ferogradumet ferrofumeraat)
* Iron injection during pregnancy
* Vaginal Tablets for fungal infection: Canesten (dotrimazol)
* Injections for lung maturation: Celestone (bètametason)
Contractions D Inhibitors (= Prepare ritodrinehydrochlorine,
nefedipine)
* Highly emotional events sometimes sedative drugs
* Alcohol
* Smoking
* Vinyl in the bedroom or other rooms in the house
* Cooking in aluminum pans
* Frequent travel by plane (or work as a flight attendant or pilot)
* High usage of mobile phones
* Wireless antenna (WiFi) wireless internet at home.
Medication during childbirth

* Medicine to induce contractions (oxytocin-Pitosin)
* Pain Medication
* Narcotics
* Soothing medication
* Sleep Medication
Major health of me during my first two years and my mother
during breast-feeding:

* Vaccinations: BCG, Hepatitis B, DTP / HIB / Pneumococcal,
MMR, Meningococcal C, DTP, tropics, influenza, HPV.
* Antibiotics
* Anesthesia
* Medication mother during breastfeeding
* Reflux medications for heartburn
* Studies with contrast (with stannous chloride)
* Inhalers for COPD (breathlessness)
* Anti-diarrheal agents: Imodium (loperamide)
* Aluminum antacids (Gaviscon, Maalox, Antagel)
* Reheating bottle in the microwave.
Home Products:
* Deodorant (containing mostly aluminum)
* Nasal Spray: Otrivin (xylometazoline), Flonase (Fluticasone
with preservatives)
* Acetaminophen also contains 40mg aspartame
* Sweeteners: aspartame, aspartame gum, diet products
* Homeopathic remedies

Source: http://www.360homeopathy.com/uploads/CEASE_checklist_clients_.pdf

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