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    Your Health History

    The purpose of the form is to find out information about your health and wellbeing so that we are best able to provide appropriate support, for you as a new patient in our practice.

    Please complete as many sections as possible. Our clinic team will review the information and may contact you to either find out a little more or offer an appointment in the clinic based on the information you've shared.

    Please note that we take your privacy seriously as per the Health Information and Privacy Act, so your answers will be treated confidentially.

    * Required Fields
    Section 1: Tell us about yourself
    Do you require an interpreter?
    (Optional)
    Do you have any special communication need? hearing, speech, need for interpreter?
    (Optional)
    Do you have a carer / home support?
    (Optional)
    Are you a carer for anyone at home?
    (Optional)
    Are you in paid employment?
    (Optional)
    Are there any barriers to accessing medical appointments?
    (Optional)
    Section 2: Medical History
    Have you had any major operations you think we should know about?
    (Optional)
    Have you had any major injuries you think we should know about?
    (Optional)
    Have you or your family (or anyone you currently live with) had any infectious diseases? (e.g., Hepatitis B, Hepatits C, HIV, Tuberculosis)
    (Optional)
    Section 3: Medication and allergy history
    Do you regularly take prescribed medications?
    (Optional)
    Do you get all prescriptions from your GP?
    (Optional)
    Do you take vitamins, homeopathic, alternative medications or Rongoa?
    (Optional)
    Do you have any allergies?
    (Optional)
    Section 4: Family History

    Have any of your whānau, blood relatives (Mother, Father, Siblings, Grandparents) suffered from the following conditions?

    If unsure please type unsure
    Section 5: Lifestyle Information
    Do you drink alcohol?
    (Optional)
    a standard drink is 1 can of beer, 100 ml of wine or 30 ml of spirits
    Do you gamble?
    (Optional)
    As a rule, do you do more than 40 minutes of moderate or vigorous exercise (such as walking or sport) on 3 or more days of the week?
    (Optional)
    Are you concerned about your weight or shape?
    (Optional)
    The next section covers women’s health topics such as pregnancy and cervical screening. Select Yes if relevant, or skip if not.
    (Optional)
    Section 6: Women's Health
    Have you ever had an abnormal cervical / HPV result?
    (Optional)
    Have you had any abnormal mammogram results?
    (Optional)
    Are you currently using any contraception?
    (Optional)
    Are you currently pregnant?
    (Optional)
    Are you planning a pregnancy?
    (Optional)
    Have you ever been pregnant?
    (Optional)
    Section 7: Emotional wellbeing and Personal safety
    Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?
    (Optional)
    Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?
    (Optional)
    Over the last 2 weeks have you been worrying a lot about everyday problems?
    (Optional)
    Is controlling your anger sometimes a problem for you?
    (Optional)