Pre-Clinic Gynaecology Health Questionnaire Only

Please ensure you have completed the patient health questionnaire well before your clinic visit.

You can fill out the online form below or if you prefer you are welcome to print off and complete the Patient Health Questionnaire and send to [email protected] or drop in to our reception. Download PDF > Patient Health Questionnaire

Please fill out online questionnaire below - make your way through all sections

Your Name *

First

Last *

Last

Date of Birth

Email *

Phone Number

Procedure requested

Please complete the questionnaire carefully by ticking the appropriate answer and giving additional information, if necessary, in the spaces provided. This information is strictly confidential.

Please make sure that you have included all relevant information to the best of your knowledge to help us to provide you with the best and safest possible care during your visit.

Which ethnicity do you identify with?

Do you need an interpreter?

YES (please state language below)

Please state language

Do you wish to have access to the Māori health service?

YES

Comments on access to the Māori health service

Do you have any cultural or spiritual needs you would like us to know about?

YES

Comments on cultural or spiritual needs

Your height in CM:

Your weight in KG:

BMI:

Please confirm the name of your Doctor and Medical Practice:

A. Anaesthetics

F. Allergies or Sensitivities – List all allergies including drugs, lotions, sticking plaster, latex. Also please let us know if you are GLUTEN FREE or have any other dietary requirements i.e., vegetarian

Do you have any allergies or sensitivities?

YES

List all allergies including drugs, lotions, sticking plaster, latex. Also please let us know if you are GLUTEN FREE or have any other dietary requirements i.e., vegetarian

Please list allergies and describe your reaction. For example, wheeze, rash, vomiting etc.

G. Medications

H. Discharge Arrangements/Information/Aftercare Consent

If you are human, leave this field blank.

Patient Health Questionnaire

Pre-Clinic Gynaecology Health Questionnaire Only

Please fill out online questionnaire below - make your way through all sections

A. Anaesthetics

B. Obstetric and Gynaecological History

C. Do you have, or have you ever had?

D. General Questions

E. How far can you walk without stopping?

F. Allergies or Sensitivities – List all allergies including drugs, lotions, sticking plaster, latex. Also please let us know if you are GLUTEN FREE or have any other dietary requirements i.e., vegetarian

G. Medications

Additional Patient Information:

H. Discharge Arrangements/Information/Aftercare Consent

Patient Confirmation of Understanding:

Pre-Clinic Gynaecology Health Questionnaire Only

Please fill out online questionnaire below - make your way through all sections

A. Anaesthetics arrowup6

B. Obstetric and Gynaecological History arrowup6

C. Do you have, or have you ever had? arrowup6

D. General Questions arrowup6

E. How far can you walk without stopping? arrowup6

F. Allergies or Sensitivities – List all allergies including drugs, lotions, sticking plaster, latex. Also please let us know if you are GLUTEN FREE or have any other dietary requirements i.e., vegetarian

G. Medications arrowup6

Additional Patient Information:

H. Discharge Arrangements/Information/Aftercare Consent arrowup6

Patient Confirmation of Understanding:

A. Anaesthetics

B. Obstetric and Gynaecological History

C. Do you have, or have you ever had?

D. General Questions

E. How far can you walk without stopping?

G. Medications

H. Discharge Arrangements/Information/Aftercare Consent