This Consultation Form will assist your therapist in correctly evaluating your needs & choosing the correct treatment for you today. All information is strictly confidential & remains the property of ZAHMAL LIMITED.

♦ Please indicate any recent or current experience of the following conditions:

Recent/Repetitive InjuryJoint ImmobilityNumbness/TinglingPain/SwellingFibromyalgiaArthritisInflammationWhiplash
High Risk:
SurgeryHeart Problem/PacemakerHigh/Low Blood PressureDigestive ProblemsDiabetes or EpilepsyCancer/Remission
Illness/ Tension:
Cold/Flu/VirusChest/BreathingAnxietyAsthmaHeadachesDizzinessSleeping ProblemsDepression
Blood ClotsThrombosisVaricose VeinsOedemaBruisingGout

Please list any physical or health conditions that your therapist should be aware of:

Please list any medication taken regularly and any specific medication/pain killers taken today:

What would you like to gain from your treatment today?:

AllergiesBotox/ Dermal FillersClaustrophobiaRetin-A/ RetinolSkin SensitivityPost Natal/Pre MenstrualContact LensesHeat SensitivityMenopausalPregnant/BreastfeedingChemical Peels
If you selected yes to allergies above, please indicate here, what type:

Does your main occupation include: Desk/Computer workPhysical ActivitiesTravel

Have you had a massage before? NoYes when last?

What type of massage would you prefer today: RelaxingRemedial

Focus Areas: Full BodyUpper BodyLower BodyHands & FeetScalp/Sinus

Pressure: LightMediumFirmDeep

How many glasses of watercaffeinated drinksdo you drinking a day? :

What type of exercise are you doing regularly hrs per week?

How do you feel today? EnergeticRelaxedTiredStressedIn Pain

Please note it is not advisable to have a treatment if you have a fever, cold or flu symptoms

How did you hear about us? Word of MouthInternetWalk byAdvertising
Please agree to our terms and conditions below.
I confirm that to the best of my knowledge, the answers I have given are correct and I have not withheld any information that may be relevant to my treatment. I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform my Therapist of my current medical or health conditions and to update this history as a current medical history is essential her/him to execute appropriate treatment procedures. I understand that ZahMal Ltd reserves the right to charge for appointments cancelled or broken without 24 hours notice.