Health Prevention Questionnaire

Health Prevention Questionnaire
Name*

First NameLast Name
Email*
example@example.com
Home Phone*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

DayMonthYear
NHI Number*
Ethnicity*
NZ Resident/Citizen*
Current GP*
Practice*
PERSONAL DECLARATION

I declare that the answers and statements in this medical report whether completed in my own handwriting, or otherwise, are true and correct to the best of my knowledge.

I understand that leaving out, or misrepresenting facts requested may compromise the Health Prevention Medical.

I authorise OneHealth GP & Urgent Care to provide a copy of my final medical report to Pacific Medical Assist Limited.

I authorise Pacific Medical Assist Limited to provide a copy of my final medical report to my current GP as detailed above.

I understand I can withdraw consent at any given time, and that I must communicate my withdrawal to the relevant clinic.
Signature*

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Date*

DayMonthYear
Date
PLEASE COMPLETE BY SELECTING YES OR NO
Are you currently being treated by a doctor for any injury or illness?*

YesNo
If yes, please provide details: *
Are you currently receiving any medical treatment or taking any medication? Prescribed or otherwise?*

YesNo
If yes, please provide details: *
Any admissions to hospital or surgical operations?*

YesNo
If yes, please provide details: *
HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING:
AsthmaLung diseaseTuberculosisHay FeverAllergyNoneAny respiratory problems
Please describe:
Heart problemsBlood vessel problemsChest painHeart murmursAny other cardiac conditionsNone
Please describe:
High or low blood pressure?*

YesNo
Please describe:
Anaemia, sickle cell state or any other blood condition? If yes, please provide details below. Please describe:*
Diabetes, Thyroid, Endocrine or Hormonal Disorders? If yes, please provide details. Please describe:*
Stomach, Liver, Indigestion, Heartburn, Peptic ulcers, Abdominal pain or Haemoptysis (vomiting blood)? If yes, please provide details.*
Intestinal problems, Haemorrhoids or Piles? If yes, please provide details below. *
Urinary problems, Kidney stones or Blood in urine? If yes, please provide details below. *
Neurological disorders, Stroke, Epilepsy, Fits or Paralysis? If yes, please provide details below. *
Frequent or severe migraines, dizziness, fainting, head injury, concussion, or unexplained unconsciousness? If yes, please provide details below. *
Nervous breakdown, or any mental illness including Depression or any other psychiatric disorder? If yes, please provide details below.*
Ear infection, Hearing problems or deafness, Eye problems, Cataracts, Ear or eye surgery? If yes, please provide details below. *
Nose, Throat, Speech disorders or Sinus problems? If yes, please provide details below. *
Back trouble (eg. Lumbago, sciatica or slipped disc with chronic or recurrent disability: including neck problems? If yes, please provide details below.*
Rheumatism, Arthritis, Joint or Limb problems? If yes, please provide details below.*
Skin problems, Growths, Tumours or Malignancies? If yes, please provide details below. *
Have you ever had treatment for alcohol or substance abuse? If yes, please provide details below. *
Do you have a medical condition that may potentially impact your current job? If yes, please provide details below. *
Any illnesses or injuries not mentioned in the above? If yes, please provide details below:*
FOR WOMEN ONLY: Any gynaecological issues or menstrual problems? If yes, please provide details below:*
FOR MEN ONLY: Have you ever been diagnosed or received treatment for any prostate problems? If yes, please provide details below.*
Alcohol (g) consumed per week?*
(10grams = 1 can of beer or 1 glass of wine or 1 nip spirit)
How many alcohol free days do you have each week?*
Guidelines say 2 alcohol free days per week
Smoking Status*

Never SmokedEx SmokerCurrent Smoker
Cigarettes per day?*
How long ago did you quit?*
Do you have any allergies?*

YesNo
Please list them.
Are you currently prescribed any medication?*

YesNo
Please list any current medications that you are currently prescribed and doses.
Have you had any surgery? If YES, please provide details below. *
Are you aware of any family member being diagnosed with cancer, heart issues, or any other disease you feel is relevant to your health? if yes, please provide details below. *
Please provide details of exercise type and how many sessions (30min or more) you do per week?*
How many servings of fruit do you consume each day? *

1

2

3

4

5

1 is , 5 is Healthy Target: 2 serves
How many servings of vegetables do you consume each day?*

1

2

3

4

5

6

1 is , 6 is Healthy Target: 6 serves
How many servings of "Grain foods and starchy vegetables" do you consume each day?*

1

2

3

4

5

6

1 is , 6 is Healthy Target: 6 or 4 for females aged 51-70
How many servings of legumes, fish, seafood, eggs, poultry or meat do you consume each day?*

1

2

3

4

5

6

1 is , 6 is Healthy Target: 2 or more serves
How many servings of "Milk, Yoghurt, Cheese (Dairy foods) do you consume each day?*

1

2

3

4

5

6

1 is , 6 is Healthy Target: 2 -3 serves or 4 for Females aged 51-70
How many takeaways do you typically have in a week?*
How many units of alcohol do you have in a week?*

01-78-1415-2121+
How many alcohol free days do you have each week?*
Guidelines say 2 alcohol free days per week
How many glasses of water do you drink each day?*
Guidelines say 6-8 glasses of water a day
How often do you eat out in a week?*

AlwaysUsuallySometimesRarelyNeverOther
For all questions, please select the appropriate response.

In the past four weeks: *

Rows	None of the time	A little of the time	Some of the time	Most of the time	All of the time
About how often did you feel tired out for no good reason?
How often did you feel nervous?
How often did you feel so nervous that nothing could calm you down?
How often did you feel hopeless?
How often did you feel restless or fidgety?
How often did you feel so restless you could not sit still?
How often did you feel depressed?
How often did you feel so sad that nothing could cheer you up?
How often did you feel worthless?

Should be Empty:

Health Prevention Questionnaire

PLEASE COMPLETE BY SELECTING YES OR NO

HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING:

For all questions, please select the appropriate response.