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Questionnaire - Tell Us About Yourself
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Your current progress:
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Gender
*
Female
Male
Age
*
Relationship status
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Married
Cohabitation
Live alone
Other
Main income
*
Work Wage
Social Benefits - Sick Leave
Work assessment allowance (AAP)
Disability Benefits
Student Loan / Scholarship
Other
How many days have you been away from work the last three months?
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Have you earlier been in contact with:
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Private psychologist / psychiatrist
Mental outpatient care
Mental Ward
Mental Homecare
None of these
How many months have you had the problem?
*
Do you have any diagnosis (given by a health professional)?
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Mental Health Diagnosis
Somatic Diagnosis
None
Highest Finished Education
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None
Primary School
High School
University / College
For What Do you Currently Use Medication?
*
Tranquilizer / Sedative
Sleep
Anti-Depressive
Medication for Mental Health Problems
Angina
Heart rhythm medication
Painkillers
Other
None
Please write the medications you currently use (type and dosage):
*
Do you think your problems are caused by a heart disease?
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Not likely
Somewhat likely
Very likely
I am certain
Do you think your problems are caused by a stress or anxiety?
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Not likely
Somewhat likely
Very likely
I am certain
What would you choose as the cause of your problems?
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Heart Disease
Anxiety / Stress
Not Sure
Why?
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How often do you experience chest pain?
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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?
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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?
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Not at all
Somewhat
A lot
Always
How much does the problems affect your functioning socially?
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Not at all
Somewhat
A lot
Always
How much does the problems affect your functioning at work / studies?
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Not at all
Somewhat
A lot
Always
Do you avoid physical activity because of your problems?
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Never
Sometimes
Often
Always
Hva you been in contact with a health professional (GP, emergency ward, health unit, hospital) regarding chest pain or palpitations?
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Yes
No
What type of contact?
*
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