WellbeingCampaignHealthCheckup |

HEALTH CHECKUP BANNER

Wellbeing Form

Instructions:
Please complete the following assessment. Your responses will help us understand and improve the health and well-being of professional drivers.

Section 1: Personal Information

Name:(Required)

First Last

Email:(Required)

Age:(Required)

Gender(Required)

Male

Female

Other

Other Gender

Occupation/Job:

Years of Driving Experience:

Nationality:

Language(Required)

Section 2: Physical Measurements (To be filled during the assessment)

Weight (in kg):(Required)

Height (in cm):(Required)

Body Mass Index (BMI):(Required)

Waist Circumference (in cm):(Required)

Blood Pressure:(Required)

Diastolic (mmHg)(Required)

Blood Glucose Level (in mg/dL):(Required)

(if available otherwise submit a default value of 99)

Oxygen Saturation Level (SpO₂ in %):(Required)

Section 3: Lifestyle and Habits

Average Hours of Exercise Per Week:(Required)

Average Hours of Sitting Per Day:(Required)

Average Hours of Sleep Per Night:(Required)

Average Daily Water Intake (in liters):(Required)

Units of Alcoholic Beverages Consumed Per Week:(Required)

Average Number of Cigarettes Smoked Per Day:(Required)

Average Number of Cooked Meals per Week:(Required)

Section 4: Mental Health Assessment

(Rate from 1 to 5)

How would you rate your stress level?

1

2

3

4

5

(1 = No stress, 5 = Extremely stressed)

How happy do you feel?

1

2

3

4

5

(1 = Very unhappy, 5 = Very happy)

How do you rate your life satisfaction?

1

2

3

4

5

(1 = Very dissatisfied, 5 = Very satisfied)

How would you rate the quality of your sleep?

1

2

3

4

5

(1 = Very poor, 5 = Excellent)

How often do you feel fatigued?

1

2

3

4

5

(1 = Rarely, 5 = Very often)

Section 5: Additional Feedback

Do you have any pre-existing medical conditions?

Yes

No

(Please specify)

Any additional comments or concerns regarding your health:

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Administrative

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BMI

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BMI

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BMI Calc

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Blood Pressure < 35

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BP < 35

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BP < 35 Calc

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Blood Pressure 36 - 55

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BP 36 - 55

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BP 36 - 55 Calc

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Blood Pressure 56 - 65

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BP 56 - 65

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BP 56 - 65 Calc

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Blood Pressure > 66

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BP > 66

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BP > 66 Calc

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Blood Glucose

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BG

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BG Calc

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Waist Circumference Men < 35

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WCM < 35

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WCM < 35 Calc

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Waist Circumference Men > 35

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WCM > 35

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WCM > 35 Calc

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Waist Circumference Women < 35

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WCW < 35

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WCW < 35 Calc

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Waist Circumference Women > 35

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WCW > 35

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WCW > 35 Calc

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Oxygen Saturation

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OS

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OS Calc

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Physical Activity

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PA

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PA Calc

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Sleep Per Night

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SPN

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SPN Calc

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Water Intake

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WI

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WI Calc

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Cooked Meals

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CM

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CM Calc

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Biological Age

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BMI

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Sport

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Tijd Zittend

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Bloeddruk Sys

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Bloeddruk Dia

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BloedGlucose < 100

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BloedGlucose 100 - 120

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BloedGlucose 121 - 140

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BloedGlucose 141 - 160

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BloedGlucose 161 - 180

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BloedGlucose 181 - 200

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BloedGlucose 201 - 220

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BloedGlucose > 220

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Buikomtrek Vrouw

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Buikomtrek

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Sleep 6 - 6.5

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Sleep 6.5 - 7

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Sleep 7 - 7.5

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Sleep 7.5 - 8

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Sleep 8 - 8.5

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Sleep > 8.5

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Sigaretten

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Water 1 - 2

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Water 2 - 3

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Water 3 - 4

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Water > 4

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Meals 4

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Meals 5

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Meals 6

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Meals 7

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Meals 8

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Meals 9

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Meals 10

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Meals 11

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Meals 12

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Meals > 12

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SPO > 98

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SPO 97 - 98

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SPO 96 - 97

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SPO 95 - 96

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SPO 94 - 95

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SPO 93 - 94

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SPO 92 - 93

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SPO 91 - 92

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SPO 90 - 91

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SPO < 90

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Alc 8

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Alc 9

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Alc 10

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Alc 11

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Alc 12

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Alc 13

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Alc 14

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Alc 15

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Alc 16

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Alc 17

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Alc 18

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Alc 19

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Alc 20

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Alc 21

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Alc 22

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Alc 23

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Alc 24

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Alc 25

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Alc 26

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Alc 27

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Alc 28

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Alc 29

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Alc 30

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Alc 31

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Alc 32

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Alc 33

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Alc > 33

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Your Biological Age

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