Forms and Leaflets

Anaesthesia Assessment – Patient Questionnaire

The NZSA and ACC jointly developed a patient questionnaire assessment form over 10 years ago.  You can download the patient questionnaire for your practice in the PDF form 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 Informed Consent, the Society produces an information leaflet about anaesthesia that may be given to patients before a medical procedure.

Your Anaesthetic – Your Anaesthetic (updated November 2018) is sold to hospitals on request and on a cost recovery basis.

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

For orders or any queries regarding this leaflet, email Lynne Wood

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


NZSA Epidural Patient Experience Survey

The 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 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.