Address and Postcode:

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/SwellingFibromyalgiaArthritisInflammationWhiplashNone
High Risk:
SurgeryHeart Problem/PacemakerHigh/Low Blood PressureDigestive ProblemsDiabetes or EpilepsyCancer/RemissionNone
Illness/ Tension:
Cold/Flu/VirusChest/BreathingAnxietyAsthmaHeadachesDizzinessSleeping ProblemsDepressionNone
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:

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:
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.