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 replying to these questions 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 a Danish CPR number*
Email*
example@example.com
Telephone number*

Area CodePhone Number
Do you have e-boks?*

YesNo
Gender*

FemaleMale
Do you have any allergies?*
Please describe your current relation with the Agency/EU Comission*

Currently employed (Annual health check)Pre-recruitment examinationLeaving/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:*

DiabetesHypertensionLung disease, e.g. lung cancer, lung fibrosis, abnormal lung x-ray or similarCancerHeart or blood vessels diseaseIntestinal disease or abnormal tool examinationI 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 a history of smoking? Please specify how much and for how long you have been smoking.*
Please specify your average alcohol consumption.*
How often do you exercise, and what type of exercise do you do?*
Please write your current medications, name and dose.*
Date for your last ophtalmological examination (eye doctor)? (Please write the month and year)*
Please specify the month and year
Date for 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?*
Do you want to be testet for HIV during the 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

How often have you experienced the following?
Stomach ache?*

AlwaysA lot of the timeSome of the timeA little bit of the timeNone of the time
Palpitations? (Noticeable pounding heart)*

AlwaysA lot of the timeSome of the timeA little bit of the timeNone of the time
Head ache?*

AlwaysA lot of the timeSome of the timeA little bit of the timeNone of the time
Muscle tension?*

AlwaysA lot of the timeSome of the timeA little bit of the timeNone of the time
Fysiske symptomer score (Min. 4, max 20 point)
Psychological symptoms during the last 4 weeks

How often have you experienced the following?
Problems concentrating?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Memory problems?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Been tense?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Diffuclty thinking clearly?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Felt exhausted?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Been emotionally burned out?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Psykiske symptomer score (Min. 6, max 30 point)
Behavioral symptoms during the last 4 weeks

How often have you experienced the following?
Difficulty falling asleep?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Waking up too early without being able to fall back asleep?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Being irritable?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Difficulty making decisions?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Been stressed?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Difficulty relaxing?*

AlwaysA lot of the timePart of the timeA little bit of the timeNone of the time
Please write at least three dates, or more, when you can attend to your upcoming examinations*
Adfærdsmæssige symptomer score (Min. 6, max 30 point)
Samlet stress score (Min. 16, max 80 point)
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