1. Health Evaluation </b
1. How do you think your health is, all in all?
2a. Have you used sleeping pills in the last 3 months?
2b. Have you used heart medication in the last 3 months?
2c. Have you used blood pressure medication in the last 3 months?
2d. Have you used nerve medicine in the last 3 months?
2e. Have you used stomach ulcer medication in the last 3 months?
2f. Have you used medication for epilepsy in the last 3 months?
2g. Have you used insulin in the last 3 months?
2h. Have you used painkillers in the last 3 months?
2i. Have you used cholesterol-lowering medication in the last 3 months?
2j. Have you used asthma / bronchitis medication in the last 3 months?
2k. Have you used allergy / itchy medication within the last 3 months?
2m. Other medicine?
3b. Do you have - or have you had - problems with heavy alcohol consumption?
3c. Do you have - or have you had - problems with other drugs?
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?
7b. Within the last 4 weeks, how often have you felt run down?
7c. Inden for de sidste 4 uger, hvornår har du følt dig anspændt ?
7d. Within the last 4 weeks, how often have you felt motivated and engaged?
7e. Within the last 4 weeks, how often has your work taken up so much of your energy that it went beyond privacy?
7f. Other relevant?
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?
9a. Do you have difficulty falling asleep?
9b. Do you have difficulty sleeping through?
9c. Do you have a feeling of tiredness?
10. Have you had one or more of the following diseases?
10a. Mental problems, e.g. stress, anxiety, nervousness
10b. Mental reactions, e.g. irritability, restlessness, sadness
10d. Appetite disorders, constipation and upset stomach (diarrhea)
10e. Gastric ulcer / Severe intestinal disease
10h. Cardiovascular disease
10j. Lung disease (eg Asthma or Allergy)
10k. Seizures (eg epilepsy - not leg cramps)
10n. Diseases of the musculoskeletal system (eg arthritis, joint, muscle or connective tissue pain).
10q. Gets breathless from walking up stairs
10r. The pressure in the chest during physical activity or cold
10s. Cough - e.g. at night or in the morning
10t. If yes in previous question:
11. Especially for women:
11a. Do you have - or have you had - Breast Cancer?
11c. Have you had problems / inconveniences during previous pregnancies?
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?
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.