Questionnaire for Health Check – NIGHT with Workplace Assessment

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

If there are questions you can’t or don’t want to answer, just skip to the next question.
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Health check - Night, with Workplace assessment
First Name / Last Name - or an Alias.
City / Branch
Example: 1970
Optional: Your E-mail if you want a copy of your answers.
Primary shift type:
1. Health Evaluation
1. How do you think your health is, all in all?
1a. Do you find that your health challenges are aggravated by night work, e.g. compared to off/holiday periods without night work?
The next 19 partial questions are for those of you who have turned 50:
1c. How satisfied are you with your job as a whole - all things considered? (10 is best)
1d. Does your work take so much of your energy that it interferes with your personal life?
Scope of your night work:
1e. How often do you work at night 4 or more nights in a row?
1f. How often do you work more than 9 hours at a time?
1g. How often do you work less than 11 hours between two shifts during a month?
1h. Night work and risk of cancer:
Is there hereditary cancer in the family?
Do you have (or have had) breast cancer?
Do you follow the screening program for bowel cancer?
Women: Do you follow mammography screening?
Women: Do you notice lumps?
Men: Are you aware of the symptoms for e.g. prostate cancer in the form of blood in urine or semen?
All citizens between the ages of 50 and 74 receive an invitation to be screened for bowel cancer every 2 years. All women between the ages of 50 and 69 receive an invitation to be screened for breast cancer every 2 years.
Discomfort in the form of pain or discomfort that can disturb sleep:
1i. Have you been bothered by any of the types of pain or discomfort mentioned here within the past 14 days?
Very bothered
A bit bothered
Pain or discomfort in the body (eg arms, shoulders, back, hands or elsewhere)
Difficulty sleeping (frequent awakenings, difficulty getting coherent sleep)
Frequent urination (e.g. in connection with sleep) or problems with urination
1j. Do you think your discomfort is aggravated by work, e.g. compared to periods when you have time off/holiday?
2. Medicine
Within the last 3 months, have you used -
1 to several times per week
1 to several times per month
Less often or never
2a. Painkillers, headache pills?
2b. Tranquilizers or nerve agents?
2c. Sleeping pills?
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
4. 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: Within the last 4 weeks -
All the time
A large part of the time
Part of the time
Some of the time
At no time
7a. How often have you slept badly and restlessly?
7b. How often have you felt out of sorts?
7c. How often have you been tense?
8. Physical discomfort: Have you had difficulty in the past 7 days in -
The neck
The shoulder
Arms / elbows
Hand / wrist
Lumbar back
The knees
Well-being at shifting
9. Why did you choose Shift / Night shift work ?: (chose max 3 options)
10. How do you thrive with shift / night shift work?
11. Do you feel rested when you get up?
12. Can you sleep undisturbed after work?
13. Have you had one or more of the following diseases?
Yes, still have
Yes, have had
13a. Heart pain (angina pectoris)
13b. Hypertension
13c. Diabetes
13d. Stomach ulcer / Severe intestinal disease
13e. Depression, requiring treatment
13f. Other mental disorder
13g. Lung disease (e.g. Asthma or Allergy)
14. Especially for women:
14a. Do you have - or have you had - Breast Cancer?
14b. Are you pregnant ?
14c. Have you had problems / inconveniences during previous pregnancies?
All companies that employ employees must prepare a written workplace risk assessment (APV). The employer is responsible for doing this and involving the employees in the process.

AGS helps collect data regarding night work if the employee answers these questions:

15. General for Workplace Assessment:
No problem
Don't know / Not applicable
15.1 Night work as a reason for sick leave
15.2 Work assignments performed exclusively as night work
15.3 Work tasks that do not need to be carried out at night
15.4 The staffing adapted to the tasks for night work
16. Occupational accidents:
No problem
Don't know / Not applicable
16.1 The time of day for accidents or near misses is recorded
16.2 Working alone which entails risks of accidents during night work
16.3. Accidents or near misses during night work
16.4. Focus on internal/external transport for night work - e.g. use of Hi Viz clothing
17. Emergency response:
No problem
Don't know / Not applicable
17.1. Special preparedness to deal with emergency situations during night work - e.g. in the event of a power outage?
17.2. Do the employees know the emergency response that comes into play in the event of incidents when working alone at night?
18. Mental working environment
No problem
Don't know / Not applicable
18.1. Possibility of contact with colleagues/manager during night work
18.2. Suitable requirements and variety for night work
18.3. Working pace adapted to night work
18.4. Risk of violence and threats during night work
19. Physical working environment:
No problem
Don't know / Not applicable
19.1. Machines that are primarily used for night work
19.2. Strenuous working positions in connection with tasks during night work
19.3. Working environment risks specifically for night work, e.g. noise, temperature, light conditions or chemical working environment
19.4. Special instruction required to carry out repairs in the event of night work breakdowns
19.5. Hazardous chemicals for night work that are not used on day or evening shifts
20. Other:
No problem
Don't know / Not applicable
20.1. Possibility of a power nap when working at night
20.2. Possibility of refreshment during night work

Slut APV spørgsmål

AG Sundhedsfremme ApS uses your answers, combined with the measured health data in the upcoming examination, 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