23 Cardrona Valley Rd, Wanaka24 Hours: 03 443 0710

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Health Questionnaire

Our Services

Opening Hours

Monday - Friday: 8.30am - 6pm

You may contact us by phone from 8.30am until 6pm.

Saturday: Doctor on duty

Sunday: Doctor on duty

Clinics are held at the duty practice between 9am – 12pm and 3pm – 6pm.

Outside of these hours, the after hours service can be contacted on 443 0710.

Personal History

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Occupation(Required)

Employer (for ACC claims)(Required)

Employer address

Do you require an interpreter service for your medical appointments?(Required)

Yes

If yes, which language?

What is your current weight?(Required)

What is your current height?(Required)

Please list all medications you are taking?

Are you taking more than 8 regular medications(Required)

Yes

Do you drink alcohol(Required)

Alcohol Guidelines

Alcohol Within Guidelines

No more than 10 (women) 15 (men) standard* drinks per week
At least 2 alcohol free days per week
Not drinking more that 6 alcoholic drinks on one occasion

*one standard drink of alcohol = 100 ml wine (12.5%) one 330ml can of beer (4%) or one 30ml shot of spirit

Have you ever smoked or vaped?(Required)

Allergies : Do you have any allergies (e.g medications, food, latex, pollen)(Required)

Yes

If yes please list:

Please list any significant illness/operations/diagnoses you have had/currently have? (including month/year if known):

Disabilities: Please describe any disabilities you have:

If applicable, when did you last have cervical screening?

Have you visited your previous general practice more than 12 times in the past year for medical concerns (Not including ACC, blood tests)?(Required)

Yes

Family History

Do you have a family history of diabetes(Required)

Yes

If yes, what relation and how old were they at the onset?

Do you have a family history of heart disease(Required)

Yes

If yes, what relation and how old were they at the onset?

Do you have a family history of stroke(Required)

Yes

If yes, what relation and how old were they at the onset?

Do you have a family history of cancer(Required)

Yes

If yes, what relation, what type of cancer and how old were that at the onset?

Please list any other relevant family history, include which relation and how old they were at the onset.

Is there any other personal or family history you wish to share with us?

Wanaka Medical Centre

Wanaka Medical is a rural general practice providing high quality medical care including accident and emergency services, to the Wanaka Community.

Contact Us

Address: 23 Cardrona Valley Road, Wanaka, New Zealand, 9305 (get directions)

Phone: 03 443 0710

Opening Hours

Monday – Friday: 8.30am to 6pm
Weekends: 9am – 12pm / 3pm – 6pm
Public Holidays: 9am – 12pm / 1pm – 6pm

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