New Zealand Society of Anaesthetists (NZSA) – Level 1, Central House, 26 Brandon Street, Wellington 6011
04 494 0124 |

Forms and Leaflets

Anaesthesia Assessment – Patient Questionnaire

The NZSA and ACC developed a patient questionnaire assessment form in 2005.  The NZSA has been producing printed forms for hospitals and distributing them for a small fee.  A PDF version has been available on the ACC website and due to the reduced demand the NZSA has stopped printing these forms.

If you are interested in receiving this patient questionnaire for your practice in its PDF form click on the below:

ACC Version






If you wish to download the most recent version in Word please click here

Word Version (2017)

Anaesthesia Assessment Patient Questionnaire Word version

 Your Anaesthetic – For Patients

As part of our commitment to the practice of Informed Consent, the Society produces information leaflets that include advice that may be given to patients before a medical procedure about the risks associated with anaesthetics.

Your Anaesthetic – Your Anaesthetic (updated in 2016) is sold to hospitals on request and on a cost recovery basis.

This leaflet can be ordered directly from the NZSA office.

The current leaflet cost is 85 cents per leaflet plus gst plus freight for orders over 1000.  For orders under 1000, the cost is $1.10 per leaflet plus gst plus freight.

For all orders or any queries regarding this leaflet, please email

Your Epidural – for patients and anaesthetists to print directly from our site.


NZSA Epidural Patient Experience Survey

The new ANZCA Continuing Professional Development Programme has three categories.  The category requiring the most effort may be practice evaluation, and there is a long list of activities suitable for this.  However, every three years you must do two activities directly relevant to your own practice from the following list of four:

• Patient experience survey
• Multi-source feedback (MsF)
• Peer review of practice
• Clinical audit of own practice or significant input into a group audit of practice.

On average, half of us will do a patient survey. The aim of the survey is to get feedback from patients on the care they received from their anaesthetist.  You need a minimum of 15 patients who “represent a good cross section of patients from your everyday practice.”

The NZSA is pleased to provide an obstetric patient questionnaire for you to use (to download).  It has been developed and successfully used over several years in New Zealand obstetric anaesthetic subspecialty units, and has been well-received by patients and midwifery staff.

The survey asks patients to rate aspects of their pre- and post-surgical care.  You do not administer the survey yourself, but instead find a willing “co-worker or assistant.” ANZCA suggests an administrative staff member or nurse.