Health Check Questionnaire – Risky Work

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.
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Health check - Risk-stressed work
First Name / Last Name - or an Alias.
Company
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?
2nd Medicine
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?
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
7a. Do you work alone?
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?
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. Sleep:
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
10c. Depression
10d. Appetite disorders, constipation and upset stomach (diarrhea)
10e. Gastric ulcer / Severe intestinal disease
10f. Hypertension
10g. Diabetes
10h. Cardiovascular disease
10i. High cholesterol
10j. Lung disease (eg Asthma or Allergy)
10k. Seizures (eg epilepsy - not leg cramps)
10m. Recurrent headache
10n. Diseases of the musculoskeletal system (eg arthritis, joint, muscle or connective tissue pain).
10o. Dizziness
10p. Nausea
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?
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