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
First Name / Last Name - or an Alias.
Company
City / Branch
Example: 1970
Optional: Your E-mail if you want a copy of your answer.
Primary shift type:
1. Health Evaluation </b
1. How do you think your health is, all in all?
1a. Do you find that your health challenges are exacerbated by your work, for example compared to time off/holiday periods?
2nd Medicine
2. Have you used the following medications within the last 3 months:
Daily
Occasionally
Have previously taken
Never
2a. Sleeping medicine?
2b. Heart medication?
2c. Blood pressure medication?
2d. Nerve medication?
2e. Stomach ulcer medicine?
2f. Medicine for epilepsy?
2g. Insulin?
2h. Painkillers?
2i. Cholesterol-lowering medication?
2j. Asthma/bronchitis medication?
2k. Allergy/itchy skin medicine?
3. Alcohol
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?
3c. Do you have - or have you had - problems with other drugs?
4. Smoking
4a. Do you smoke daily?
5. Diet </b
5a. How often do you usually eat fruit, salad, raw or cooked vegetables (apart from potatoes)?
6. Physical activity and exercise
6. Which description suits you best?
7. Well-being
Often
Occasionally
Rarely
Never
7a. Do you work alone?
7b. Within the last 4 weeks, how often have you felt exhausted?
7c. Within the last 4 weeks, when have you felt tense?
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 interfered with your personal life?
8. Physical pain problems
8. Physical discomfort: Have you had - within the past 7 days?
Yes
No
8a. Neck pain?
8b. Shoulder discomfort?
8c. Arm/elbow problems?
8d. Hand/wrist discomfort?
8e. Lower back pain?
8f. Knee problems?
9. Sleep:
No
Yes, but rarely
Yes, often
Yes, always
9a. Do you have difficulty falling asleep?
9b. Do you have difficulty sleeping through the night?
9c. Do you feel tired?
10. Sygdomme:
10. Have you had one or more of the following illnesses?
Yes, still have
Yes, have had
No
10a. Psychological problems, e.g. stress, anxiety, nervousness
10b. Mental reactions, e.g. irritability, restlessness, sadness
10c. Depression
10d. Appetite disturbances, constipation and loose stomach (diarrhea)
10e. Stomach ulcer / Severe intestinal disease
10f. High blood pressure
10g. Diabetes
10h. Cardiovascular diseases
10i. Elevated cholesterol
10j. Lung disease (e.g. asthma or allergies)
10k. Convulsions (e.g. epilepsy - not leg cramps)
10m. Recurrent headaches
10n. Musculoskeletal diseases (e.g. arthritis, joint, muscle or connective tissue pain)
10o. Dizziness
10p. Nausea
10q. Gets out of breath when walking up stairs
10r. 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?
11b. Are you pregnant ?
11c. Have you had problems / inconveniences during previous pregnancies?
ENDING
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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