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Consultation Form

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 London LTD.

♦ 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 drinks do you drink per 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 MouthInternetPop upAdvertising
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 London LTD. reserves the right to charge for appointments cancelled or broken without 24 hours notice.

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