Perkeso Questionnaire
Perkeso Questionnaire
Personal Details
Full Name as per IC
IC Number
Mobile Number
Email
Job Title
Ethnicity
Malay
Chinese
India
Bumiputera
Gender
Male
Female
Do you have SEHATI apps by PERKESO ?
Yes
No
Company Name
Marriage Status
Married
Single
Widowed
Divorced
Do you have any children?
Yes
No
Number of Children
Highest Education Achieved
State
Postcode
QUESTIONNAIRE
1. Have the worker ever done a health screening prior to SOCSO's Health Screening Programme?
Yes
No
2. Does the worker have any disability?
Yes
No
3. Occupational classifications
Managers
Professional
Technicians and Associate Professionals
Clerical Support Workers
Service and Sales Workers
Skilled Agricultural, Forestry and Fishery Workers
Craft and Related Trades Workers
Plant and Machine-Operators and Assemblers
Elementary Occupations
4. Occupational hazards
Physical
Psychosocial
Ergonomic
Biological
Chemical
5. Occupational Medical Surveillance
Yes
No
6. Do you have allergy?
Yes
No
If 'Yes', please tick:
Nuts
Eggs
Gluten (wheat, grains)
Soy
Milk
Dust
Seafood
Fur
7. Have you been diagnosed with any medical illness?
Yes
No
If 'Yes', please tick:
Stroke
Diabetes
Hypertension
High Cholesterol
Cancer
Mental Health
Asthma
Heart Disease
Arthritis
Blood clots
Glaucoma
8. Activity Level
Sendetary
Light Active
Moderately Active
Intense Weight Training Program / sports 4-5 days per week
Very Active
Extra Active
9. Are you regularly smoking cigarette or any form of tobacco?
Yes
No
10. Symptoms History
I am currently pregnant / may be pregnant
Indigestion, nausea, heartburn
Urinary problems
Urine, poor flow of urine
Headaches, dizziness, fainting spells
Ears
Menstrual
Persistent coughing, breathlessness, coughing blood
Diarrhoea, constipation, blood in stool, black colour stool
Skin problems
Mood changes, insomnia, anxiety, stress
Abnormal lumps noticed
Chest pain, palpitations
Loss of weight, loss of appetite
Weakness of limbs
Eyes
Musculoskeletal
None
11. Medications that you are currently taking
No medications
No medications
12. Any surgeries you had in the past?
No surgeries
No surgeries
FAMILY HISTORY
(1st degree only : grandparents, parents, brothers and sisters, children)
13. Family Illness History
Heart Disease
High Cholesterol
Arthritis
Stroke
Cancers
Blood Clots
Diabetes
Mental Health
Glaucoma
Hypertension
Asthma
Kidney Failure
14. Do you consume alcohol?
Yes
No
15. How many portions of fruit or vegetables per day?
(1 portion = 1 apple/4 spoons of vegetables)
0
1
2
3
4
5
More than 5
16. Are you taking any herbal or pharmaceutical supplements regularly?
Yes
No
17. Have you had more than 2 sexual partners in the past 6 months?
Yes
No
18. Do you have any history of dialysis / blood transfusions?
Yes
No
FOR FEMALE EMPLOYEE
The worker has a family history of breast cancer (mother, sister or daughters ever had breast cancer)?
Yes
No
The worker is a carrier of BRCA1 or BRCA2?
Yes
No
The worker has a history of atypia on breast biopsy?
Yes
No
The worker has no children or a first child after the age of 30 years?
Yes
No
The worker has her first menstrual period at the age of 12 years or younger?
Yes
No
The worker had her menopause after the age of 55 years?
Yes
No
The worker is currently on hormone replacement therapy?
Yes
No
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