Questionnaire in connection with your Health Examination
Name
CPR number
E-mail + mobile no.
Job title
Single/cohabiting
Children, age
Type a question
Rows
No
Yes
Please specify
Have you previously had any health issues
Have you had any health issues since you last examination
Do you have any allergies
Do you have any symptoms from the heart
(Chest pains, irregular pulse,high blood pressure)
Do you have any issues with your stomach or bowels
(Pain, nausea, vomiting, weight loss, bowel movement)
Do you have any symptoms from the urinary system
(Urinary difficulties,unintentionally or nocturnal urination, erectiledysfunction)
Do you have any symptoms from the nervous system
(Head ache, dizziness, fainting, change of sensation in arms or legs)
Do you have any issues with your back or joints
(Pain, reduced strength, reduced mobility)
Eye symptoms
Ear symptoms
Do you have diabetes or metabolic disorder
Do you have any skin issues
Psychological
(Depression, anxiety, stress, abuse)
Female; Do you have any gynecological issues (Menstruation pattern, menopause, pains)
Do you use medication including naturopathic drugs
Sleep; how do you sleep
Do you exercise regularly, how many hours per week
Do you smoke
Do you use nicotine products or cannabis
How much alcohol do you consume during the week
Do you think you ought to drink less
Describe your dietary habits
How many glasses of water do you drink during the day
Do you have any travel activity in connection with work
Are there any special issues you would like to discuss during your examination
Hereditary diseases in immediate family. Please tick below
Rows
Mother
Father
Any Siblings?
Children
Increased cholesterol
Cardiovascular diseases
Diabetes
Mental disorders
Cancer
May we send the finished report of your examination to your e-mail address?
example@example.com
May we send you an email when it is time for the next medical examination?
Yes
No
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