Health Check Questionnaire – Risky Work

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

If there are 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 be in the Spam folder).
If you would like a copy of your reply sent to your mail, please fill in the Email field below (Might be in the Spam folder).

Health check - Risk-stressed work

Name *

First Name / Last Name - or an Alias.

Company *

Company

City *

City / Branch

Year of birth *

Example: 1970

E-mail

Optional: Your E-mail if you want a copy of your answer.

1. Health Evaluation </b

1a. Oplever du, at dine helbredsudfordringer forværres af dit arbejde f.eks. sammenlignet med fri-/ferieperioder?

Nej

Ved ikke

2nd Medicine

2m. Other medicine?

3. Alcohol

3a. How many items do you drink on average per week:

Example: 30 - (One item is a beer, a glass of wine, 2 cl spirits)

3b. Do you have - or have you had - problems with heavy alcohol consumption?

Yes

Yes, have had

3c. Do you have - or have you had - problems with other drugs?

Yes

Yes, have had

4. Smoking

4a. Do you smoke daily?

Yes

No, but have smoked in the past

No, have never smoked

If smoker, how much per day?

5. Diet </b

5a. How often do you usually eat fruit, salad, raw or cooked vegetables (apart from potatoes)?

5b. How many times a day do you eat?

6. Physical activity and exercise

6. Which description suits you best?

Almost completely physically passive or light physical activity less than 2 hours per week.

Light physical activity 2-4 hours per week (walk, gardening, light gymnastics).

Light physical activity more than 4 hours per week or more strenuous activity 1-2 hours per week (brisk walking or cycling, heavy gardening, exercise where you get short of breath or sweat).

More strenuous physical activity for more than 4 hours or regular hard training / competition several times per week.

7. Well-being

7f. Other relevant?

8. Physical pain problems

9. Sleep:

10s. Cough - e.g. at night or in the morning

Yes

Yes, have had

10t. If yes in previous question:

Dry cough ?

Cough with mucus?

11. Especially for women:

11a. Do you have - or have you had - Breast Cancer?

Yes, still have

Yes, have had

11b. Are you pregnant ?

Yes

11c. Have you had problems / inconveniences during previous pregnancies?

Yes

ENDING

Is there anything else you want to inform us about before the survey? (Eg any omissions in the content of the survey)

Comments on the questionnaire?

I hereby give AG Sundhedsfremme ApS the right to store and store my information so that it can be used in my upcoming examination.

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

If you are human, leave this field blank.

+45 20 22 90 62 info@agsundhed.dk

Health Check Questionnaire – Risky Work

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