Questionnaire - Tell Us About Yourself

Your current progress:

Gender *

Female

Male

Age *

Relationship status *

Married

Cohabitation

Live alone

Other

Main income *

How many days have you been away from work the last three months? *

Have you earlier been in contact with: *

How many months have you had the problem? *

Do you have any diagnosis (given by a health professional)? *

Mental Health Diagnosis

Somatic Diagnosis

None

Highest Finished Education *

None

Primary School

High School

University / College

Please write the medications you currently use (type and dosage): *

Do you think your problems are caused by a heart disease? *

Not likely

Somewhat likely

Very likely

I am certain

Do you think your problems are caused by a stress or anxiety? *

Not likely

Somewhat likely

Very likely

I am certain

What would you choose as the cause of your problems? *

Heart Disease

Anxiety / Stress

Not Sure

Why? *

How often do you experience chest pain? *

Not for the last 6 months

At Least Every Month

At Least Every Week

Every Day

How often do you experience unpleasant palpitations / rapid pulse? *

Not for the last 6 months

At Least Every Month

At Least Every Week

Every Day

How much does the problems affect your functioning in your family? *

Not at all

Somewhat

A lot

Always

How much does the problems affect your functioning socially? *

Not at all

Somewhat

A lot

Always

How much does the problems affect your functioning at work / studies? *

Not at all

Somewhat

A lot

Always

Do you avoid physical activity because of your problems? *

Never

Sometimes

Often

Always

Hva you been in contact with a health professional (GP, emergency ward, health unit, hospital) regarding chest pain or palpitations? *

Yes

What type of contact? *

Leave this field blank: