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: Muscular/joint:Recent/Repetitive InjuryJoint ImmobilityNumbness/TinglingPain/SwellingFibromyalgiaArthritisInflammationWhiplashNone High Risk:SurgeryHeart Problem/PacemakerHigh/Low Blood PressureDigestive ProblemsDiabetes or EpilepsyCancer/RemissionNone Illness/ Tension:Cold/Flu/VirusChest/BreathingAnxietyAsthmaHeadachesDizzinessSleeping ProblemsDepressionNone Circulatory:Blood ClotsThrombosisVaricose VeinsOedemaBruisingGoutNone 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?: FACE & BODY SECTION :AllergiesBotox/ Dermal FillersClaustrophobiaRetin-A/ RetinolSkin SensitivityPost Natal/Pre MenstrualContact LensesHeat SensitivityMenopausalPregnant/BreastfeedingChemical PeelsNone If you selected yes to allergies above, please indicate here, what type: MASSAGE SECTION : 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/SinusAll Pressure: LightMediumFirmDeepAny GENERAL SECTION : How many glasses of water and caffeinated drinksdo you drinking a day? : What type of exercise are you doing regularly , how many 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 byAdvertisingWowcher 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.