Pre-Procedure Health Questionnaire Online Form

Please ensure you have completed the patient health questionnaire well before your surgical/procedure date.

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

Pre-Procedure Health Questionnaire

Please complete the questionnaire carefully by selecting the appropriate answer and giving additional information, if necessary, in the spaces provided. 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.

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

B. Have you ever had any of the following procedures?

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