Health Check Questionnaire

Answering this questionnaire is optional. You can read about our protection of your personal data here.

If there are any questions you cannot or will not answer, simply skip to the next question.
If you would like a copy of your reply sent to your mail, please fill in the Email field below (Might end up in the Spam folder).

Health Check
First Name / Last Name - or an Alias.
Company
Example: 1970
Optional: Your E-mail if you want a copy of your answers.
1. Health Evaluation
How do you think your health is, all in all?
2. Medicine
2a. Have you used painkillers, headache pills in the last 3 months?
2b. Have you used sedatives or nerve medicine in the last 3 months?
2c. Have you used sleeping pills in the last 3 months?
3. Alcohol
Example: 30 - (One item is a beer, a glass of wine, 2 cl spirits)
Do you have - or have you had - problems with heavy alcohol consumption?
Do you have - or have you had - problems with other drugs?
4. Smoking
Do you smoke daily?
5. Diet
5. How often do you usually eat fruit, salad / raw food, cooked vegetables (apart from potatoes)?
6. Physical activity and exercise
6. Which description suits you best?
7. Mental health
7a. In the last 4 weeks, how often have you slept badly and restlessly?
7b. Within the last 4 weeks, how often have you felt run down?
7c. Within the last 4 weeks, how often have you been tense?
8. Physical pain problems
8a. Have you had neck problems in the last 7 days?
8b. Have you had shoulder problems within the last 7 days?
8c. Have you had problems with your arms / elbows within the last 7 days?
8d. Have you had problems with your hand / wrist within the last 7 days?
8e. Have you had low back pain in the last 7 days?
8f. Have you had knee problems in the last 7 days?
9. Have you had one or more of the following diseases?
9a. Heart pain (angina pectoris)
9b. Hypertension
9c. Diabetes
9d. Gastric ulcer / Severe intestinal disease
9e. Depression, requiring treatment
9f. Other mental illness
9g. Lung disease (eg Asthma or Allergy)
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AG Sundhedsfremme ApS uses your answers, combined with the measured health data in the upcoming survey, to advise you about your health. The answer will, in anonymised form, also be included in a comprehensive report to the company, however in such a way that no individuals can be identified. When you give your consent for the above purpose, you also give AG Sundhedsfremme's nurses and statisticians the right to process your information in this questionnaire. You can always withdraw your consent by writing to ANTR@AGSundhed.dk