Lægerne på Strandvejen | Digital Anamnesis

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 nameLast name
Date of birth

MonthDayYear
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 CodePhone Number
Do you use the Danish e-boks?
What is your gender?
What sex were you assigned at birth?
Please describe your current relation with the Agency/EU Comission
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:
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?
Palpitations? (Rapid heartbeat)
A feeling of heavy weight on the chest?
Head ache?
Muscle tension?
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?
Memory problems?
Been tense?
Diffuclty thinking clearly?
Felt exhausted?
Been emotionally burned out?
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?
Waking up too early without being able to fall back asleep?
Being irritable?
Difficulty making decisions?
Been stressed?
Difficulty relaxing?
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.
Should be Empty:

Questions for EEA/EU staff members

Stress test

Physical symptoms during the last 4 weeks

Psychological symptoms during the last 4 weeks

Behavioral symptoms during the last 4 weeks

Thank you