Questions for EEA/EU staff members
Thank you for your interest in your own health. We are pleased to help you. By completing the pre-questionnaire you have started your medical examination, and you agree to have your medical information shared with relevant medical departments participating in the examination. No medical information will be shared with your employer.
Name
*
First name
Last name
Date of birth
*
/
Month
/
Day
Year
Date
Type your Danish CPR number, all 10 digits:
*
Type 0 if you do not have or use a Danish CPR number*
Email
*
example@example.com
Telephone number
*
-
Area Code
Phone Number
Do you use the Danish e-boks?
*
Yes
No
What is your gender?
*
Male
Female
Non-binary / third gender
Prefer to self-describe
Prefer not to say
What sex were you assigned at birth?
*
Female
Male
Prefer not to say
Please describe your current relation with the Agency/EU Comission
*
Currently employed (Annual health check)
Pre-recruitment examination
Leaving/retiring the Agency/Commission
Please write the history of illnesses in your nearest family (parents and siblings). Only write significant diseases such as cardiovascular diseases, cancer or similar.
*
Please tick the box and specify if you have a history of:
*
Diabetes
Hypertension
Lung disease, e.g. lung cancer, lung fibrosis, abnormal lung x-ray or similar
Cancer
Heart or blood vessels disease
Intestinal disease or abnormal tool examination
I don't have a history of any of the above
Please specify
*
Please write your history of chronic illnesses, not limited to the conditions from the previous question. You should not write insignificant illness such as common colds and simple infections.
*
Do you have any allergies?
*
Do you have a history of smoking? Please specify how much and for how long you have been smoking.
*
Please specify your average alcohol consumption per week.
*
How often do you exercise per week, and what type of exercise do you do?
*
Please write your current medications, name and dose.
*
Date of your last ophtalmological examination (eye doctor)? (Please write the month and year)
*
Please specify the month and year
Date of your last gynaecological examination? (Please write the month and year)
*
Please specify the month and year
Do you have a history of breast disease or abnormal findings on mammography?
*
Would you, if relevant, like the health check doctor to examine your breasts clinically by manual palpation?
*
Would you, if relevant, like the health check doctor to examine your prostate clinically by rectal examination?
*
Would you like to be tested for HIV as part of your blood samples?
*
Do you have any current physical complaints or symptoms?
*
Do you have any mental problems or symptoms at the moment?
*
Stress test
Stress test source: Chief physician, dr.med. and stress researcher Bo Netterstrøm
Physical symptoms during the last 4 weeks
Have you, within the last 4 weeks experienced:
Stomach ache?
*
Always
A lot of the time
Some of the time
A little bit of the time
None of the time
Palpitations? (Rapid heartbeat)
*
Always
A lot of the time
Some of the time
A little bit of the time
None of the time
A feeling of heavy weight on the chest?
*
Always
A lot of the time
Some of the time
A little bit of the time
None of the time
Head ache?
*
Always
A lot of the time
Some of the time
A little bit of the time
None of the time
Muscle tension?
*
Always
A lot of the time
Some of the time
A little bit of the time
None of the time
Fysiske symptomer score (Min. 4, max 25 point)
Psychological symptoms during the last 4 weeks
Have you, within the last 4 weeks, experienced:
Problems concentrating?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Memory problems?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Been tense?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Diffuclty thinking clearly?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Felt exhausted?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Been emotionally burned out?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Psykiske symptomer score (Min. 6, max 30 point)
Behavioral symptoms during the last 4 weeks
Have you, within the last 4 weeks experienced:
Difficulty falling asleep?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Waking up too early without being able to fall back asleep?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Being irritable?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Difficulty making decisions?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Been stressed?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Difficulty relaxing?
*
Always
A lot of the time
Part of the time
A little bit of the time
None of the time
Please write as many dates as possible (at least 5 dates) when you can attend your upcoming examinations*
*
*The timeslots vary but can be expected from 08:00-17:00) (only dates in the month your medical examination is due)
Adfærdsmæssige symptomer score (Min. 6, max 30 point)
Samlet stress score (Min. 16, max 85 point)
Thank you
Thank you for taking the time to reflect and complete your pre-questionnaire. You can save and print your questionnaire answers below. Remember to submit the form afterwards.
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