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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:
    Covid-19SurgeryHeart 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 that is not listed above:

    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 FillersChemical peelClaustrophobiaRetin-A/ RetinolSkin SensitivityPost Natal/Pre MenstrualContact LensesHeat SensitivityMenopausalPregnant/BreastfeedingChemical PeelsNone
    If you selected yes to allergies above, please indicate here, what type:
    NAILS :
    SplitPeelCrackBreakToo softToo HardDryCallusIngrown nailWartsAthlete's FootCrackBleedOpen Cuts Wounds SoresNone
    Do you have any other issues/infections with the nails/hands/feet that your therapist needs to know?, please indicate here.:
    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, your Practitioner will NOT be doing any treatments if anyone in the household is isolating or have symptoms of Covid-19. Please contact us up to 6 hours before the time of treatment to cancel or reschedule your appointment. Note that you will not be refunded upon arrival, therapist will communicate with ZahMal London Admin team.READ

    How did you hear about us? Word of MouthInternetPop upAdvertising
    Please agree to our terms and conditions below.
    I confirm that I am over 16 and 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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