Questionnaire in connection with your health examination
Name
CPR number
E-mail + mobile no.
Job title
Single/cohabiting/married
Children, age
Your health. Please tick each question and add details if relevant.
Rows
No
Yes
Please specify
Have you previously had any health issues?
Have you had any health issues since your 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 movements)
Do you have any symptoms from the urinary system?
(Urinary difficulties, unintentional or nocturnal urination, erectile dysfunction)
Do you have any symptoms from the nervous system?
(Headache, 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 a metabolic disorder?
Do you have any skin issues?
Psychological
(Depression, anxiety, stress, abuse)
Female: Do you have any gynaecological issues? (Menstruation pattern, menopause, pains)
Do you use medication, including naturopathic remedies?
Sleep: how do you sleep?
Do you exercise regularly, and 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
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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