The form needs to be completed in one sitting (you cannot save your work and come back to it).
Please phone us on 0508 364 436 if you cannot complete the form, or do not feel comfortable completing it.
You can read the CCDHB Privacy Policy here.
If you prefer to complete a paper copy, please go to the Genetic Health Service New Zealand website, where you can download a form and print
Alternatively we can mail you a questionnaire if you do not have access to a printer - phone us on 0508 364 436 if you would like us to send you a paper copy.
If you are having difficulty filling out this form, please complete as much as you are able to. We will discuss the details further at your appointment.
You only need to fill in your partner’s details if you have had children together or are planning to.
* For your close relatives please fill out the names and general information for everyone. * If you are adopted and do not have information on your biological relatives, please write “adopted” beside your name and return the form to us. * If any of your relatives are half brothers or sisters, please write “half” and tell us which parent you share. * If some of your relatives are not related by blood (eg stepbrothers or stepsisters), please do not list them. * If anyone in your family has changed their name, please list both the previous name and the name change.
Please indicate next to full name Male/Female and whether F/HM/HF as per Relationship Key above Please also list miscarriages and stillbirths
Please indicate next to full name Male/Female and whether F/HM/HF as per Relationship Key above
Please indicate next to full name whether F / HM / HF as per Relationship Key.
Please indicate next to full name whether F / HM / HF as per Relationship Key
Healthline
GP
Afterhours
Hospital ED