Health History Form1 2 3 4 5 6 7 Please take the time to fill in this form prior to treatment.This consultation form assists therapists and health/lifestyle coaches in evaluating your needs and goals and to work out a structured, easy to follow, step by step plan to reach your desired outcome. While we treat from the inside out to achieve good skin health, our advice and philosophy is based on whole foods, maintaining good gut health, home compliance, and in-house treatments. We work closely with each individual and customise each plan to suit individual’s needs and goals. Our health coach and corneotherapists guide, support, educate and empower you back to health, so therefore everything we do at House of Maxx is designed for you.All information is strictly confidential & remains the property of House of Maxx.Name* First Last Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact number*Email* Address* Street Address City State Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Place of birth*Have you lived out of the country or climate from where you grew up for longer than 12 months?YesNoIf yes please indicate where and length of time?*Was your skin or health better or worse?*What do you hope to achieve from your visit to House of Maxx?* Please indicate any recent or current experience of the following conditions Recent injury Cancer/remission Circulation/Lymph Issues Numbness/Tingling High blood pressure Thyroid Condition Menopausal Claustrophobia Asthma Arthritis HIV Depression/Anxiety Recent surgery Hepatitis Epilepsy Heart problems Diabetes Pregnant/Breast FeedingDoes your weight fluctuate?*YesNoHave you had any form of acne treatment such as Roaccutane/Retin A or prescribed medications for a skin condition?Have you ever had Dermal Fillers/Botox Chemical Peels Microdermabrasion Laser/IPL/FraxelDermal Fillers/Botox*Location of treatmentDate of treatmentType of treatmentChemical Peels*Location of treatmentDate of treatmentType of treatmentMicrodermabrasion*Location of treatmentDate of treatmentType of treatmentLaser/IPL/Fraxel*Location of treatmentDate of treatmentType of treatment Social InformationStress plays a huge role in how our skin and gut/brain health perform. Emotional, physical and environmental stress is all classified as stress.Do you suffer from anxiety or depression?If so please provide a detailed history or you emotional/mental health. How long have you been feeling like this, are you currently under any medical or alternate therapy and have you been diagnosed with a mental illness?Do you regularly exercise?*YesNoDo you participate in any high impact or intense sport?*YesNoIf yes how many hours do you perform each week and what time of the day do you exercise?*Do you participate in any low impact activities such as Yoga, Pilates or Walking?*YesNoIf yes how many hours and what do you do?*Occupation*Occupation stress*Low stressHigh stressHow many hours a week do you work?* Health InformationBirth history*Natural or vaginal birthPrematureCaesarean (emergency or elective)Any other relevant information regarding your birth?What birth or sibling number are you?*Were you breast fed?*YesNoIf yes, for how long?*Were you bottle fed?*YesNoIf yes, formula (cow or other) or breast milk?*How was the health of your mother during pregnancy and leading up to birth?*WellUnwellIf unwell, please explain*As a child did you suffer from any of the following Ear infections Throat infections Eczema Allergies Hay fever Nappy rash Conjunctivitis Cradle cap Glandular fever Asthma Sinus problems BronchitisAt any time in your life have you suffered from the following Thrush UTI’s Vaginitis Endometriosis PCOS Infertility Menstrual Irregularities Brain fog Fungal infections of the skin and nails Lethargy Anxiety or depression Headaches Pain and swelling in the joints Abdominal cramps Allergies/sensitivities and or food intolerances Bloating/ Belching Constipation/ Diarrhoea Cold hands and feet Bad breath Body odour not relieved by washing Burning on urinationIf Allergies/sensitivities and or food intolerances please explain*Please list any health concerns that are present todayAt what point in your life did you feel your best and why?Have you had any serious illnesses or injuries? If Yes, please explainHow was/is the health of your mother?How was/is the health of your father?What is your heritage?What is your blood type?How many hours sleep do you get a night?Is it interrupted?*YesNoIf Yes, please explain. Medical informationPlease list any supplements and medications you are currently takingAre you under any medical care or alternate therapy? Dietary / Nutrition informationIn integrative Nutrition we talk about primary and secondary foods. Primary foods are the parts of our life that nurture our body, mind and spirit, while secondary foods are foods we eat to nourish our body nutritionally.Fun health factOur body is always striving to maintain balance or homeostasis. The gut/brain is connected both biochemically and physically. Neurons are cells found in both the brain and the gut and they are both connected to each other through the nerves in your nervous system. The vagus nerve is the biggest nerve and it’s connected to the brain and gut and sends messages backwards and forwards to each other. Your gut and brain are also connected to chemicals called neurotransmitters. Neurotransmitters in the brain control feelings and emotions such as serotonin which produce feelings of happiness and also the body clock.Interestingly, many of these neurotransmitters are also produced by the gut cells and the trillions of microbes living there. 90% of your serotonin is produced in your gut. Your gut microbes also produce a neurotransmitter called gamma-aminobutyric acid (GABA) which helps control feelings of fear and anxiety. When one is out of balance then the other is impacted. Healthy gut and healthy brain leads to a healthy happy skin.Our skin is more than just a covering. It is the largest organ and responds to our outer stimuli and stimuli from within. This is why our skin can be an indicator of our health as it shows signs of stress and illness.Tell us about the memory of food you had as a child? Was food regarded as a source of comfort? Was it hard to come by so therefore you ate what there was and when you could? Did you sit down as a family and partake of food at the table or did you eat on the run? Was food considered as nurturing, nutritional, indulgent or have guilt and shame attached to it?*What food did you eat often as a child for breakfast?*What food did you eat often as a child for lunch?*What food did you eat often as a child for dinner?*What food did you eat often as a child for snacks?*Fluid intake* Water Cordial Soft drink MilkPlease choose from the followingButter / Margarine*ButterMargarineBread*White breadWholemeal breadMilk*Milk & Dairy ProductsSoy & AlternativesWhat foods did you crave as a child?*What foods did you dislike?*What foods do you eat often now for breakfast?*What foods do you eat often now for lunch?*What foods do you eat often now for dinner?*What foods do you eat often now for snacks?*Daily Water Intake*Do you crave any of the following* Sugar Caffeine Alcohol ChocolateIs there any additional information that you would like to share? I confirm to the best of my knowledge that the information I have provided is correct and I have not withheld any information that may be relevant to my consultation. I certify that the proceeding medical, health and personal history statements are true and correct. I understand it is my responsibility to inform my health coach of any current medical or health conditions and to inform House of Maxx of any changes in the future as this is essential to execute correct coaching procedures.House of Maxx take no responsibility for lack of results in the case of clients not being compliant with prescriptions or protocols.I understand that House of Maxx has the right to charge for appointments cancelled or broken within 24 hours’ notice.SignatureCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.