PRELIMINARY DATA SHEET FOR OCCUPATIONAL HEALTH EXAMINATION

PERSONAL DATA
Last name / First names
Identity code / Address
Company name / Department / Occupation/task
For each question, please select the option(s) best describing your situation. The information entered in the form is only for the use of occupational health care professionals and will remain confidential.
WORK AND OCCUPATIONAL WELL-BEING
1. Describe your current task in a few words.
2. What makes you enjoy your work and feel you are performing a meaningful task? Which things run smoothly at work?
3. How have changes in your work affected your occupational well-being, and how have these change-related challenges been addressed at work?
4. Describe a recurring situation that hinders the smoothness of work and/or succeeding in work and is thus irritating.
5. In your work, can you influence matters that are important to you (e.g., the content, development, amount, and methods of work)?
1. Not at all / 2. A little / 3. To some extent / 4. A lot / 5. Very much
. How often do you work overtime or take work home to complete in the evening?
1. Daily/weekly
2. Monthly
3. Rarely
4. Never
7. Does your work often include...
Shift work? / No / Yes days per month
Travel? / No / Yes days per month
Evening events? / No / Yes times per month
Work over the weekend? / No / Yes times per month
8. Does your work involve an excessive mental load? 9. Is your work physically...?
1. Not at all
2. A little
3. To some extent
4. A fair amount
5. Very much so / 1. Easy
2. Fairly easy
3. Average in demand
4. Fairly hard
5. Very hard
What are your expectations with respect to the operations of Occupational Health Care in relation to your health and well-being?
HEALTH STATUS AND LIFESTYLE
10. Over the last six months, have you suffered from prolonged or recurrent mental or physical discomfort or symptoms
that, in your opinion, are caused or aggravated by work?
No Possibly Yes
11. Can work-related measures help you cope with your work?
No Possibly Yes
If you answered ‘Possibly’ or ‘Yes’, please explain what kinds of measures are needed.
12. In comparison to other people your age, how would you assess your health status?
Good or excellent Average Poor or extremely poor
13. On the basis of your current state of health, do you think you will be able to handle your current occupation in two years?
Probably I don't know It is unlikely
14. Select the number that best corresponds to your current working ability. (10 = the best possible working ability; 0 = I am incapable of work).
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
15. Over the last month, have you often been worried about feelings of melancholy, depression, or despair?
No Yes
16.In the last month, have you often worried about apathy or lack of interest?
No Yes
17. Do you have an illness or ailment for which you receive continuous treatment or medication?
No Yes If ‘Yes’, please explain:
18. Does the above-mentioned illness or ailment cause inconvenience in your current job?
No Yes
19. Do you eat regularly and maintain a healthy diet, or do you think your eating habits should be improved?
20. Do you smoke cigarettes or a pipe or use snuff or chewing tobacco?
No Yes If ‘Yes’, please explain:
Approximately how much daily?
21. Do you consume alcohol?
No Yes If ‘Yes’, how many portions of alcohol do you consume per week?
(1 portion = 1 bottle of medium-strength beer, 12 cl of wine or 1 bar portion of strong alcohol)
Does the use of alcohol cause you health, social, or other problems?
No Yes
22. Do you use narcotic drugs?
No Yes If ‘Yes’, what?
23. How often during the week do you exercise (either for the purpose of exercising or in the course of daily activities),
for at least 15 minutes at a time, to such an extent that you sweat and get out of breath?
24. Do you sleep well?
Yes No If ‘No’, what kind of sleep problems do you have?
25. Do you feel that the various aspects of your life (work, family, friends, hobbies, and so on) are well balanced?
Yes No If ‘No’, what kinds of problems do you have?
26. Which things in your personal life do you find relaxing, refreshing, and enjoyable?

PRELIMINARY DATA SHEET FOR OCCUPATIONAL HEALTH EXAMINATION PAGE 1