Cognex Initial Questionnaire 2017
This is a form so we can gather all the information required to ensure you get the most out of the program. By submitting this form you are agreeing that all the information you supply is accurate to the best of your knowledge.
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
This is just to make sure your team can contact you should there be a reason to.
Your answer
Email Address *
We will only send you information relevant to the program.
Your answer
What department/Depot do you work in? *
This is to make sure we can assign you a team, if need be, with co-workers you interact with every day.
Your answer
What height are you in meters? *
Your answer
What is your current weight in kg's? *
Your answer
1. How many hours per week do you exercise (walk, run, cycle, gym)? *
Physically active is anything that gets your heart rate above normal for at least 10 minutes.
2.How much water do you drink in an average day? *
Answer in Litres
3. How many days in advance would you plan your meals? *
4. On average how many hours do you spend sitting looking at a screen per day? *
TV, Phone, Computer, Tablet etc.
Your answer
5. Do you have a set bed/wake-up time based on your work schedule? *
6. Would you normally choose to eat brown pasta/rice/bread over its white version? *
7. In a typical work day how many times do you feel stressed? *
8. Have you ever been told by a doctor not to take part in an exercise program? *
If you do not have any medical issue that would impact on your capacity to take part in this program answer "No". If you answer "Yes" please briefly explain
Your answer
9. Do you have any injuries that may prohibit you from participating in this program? *
If you answer "yes" please explain. Otherwise answer "no"
Your answer
10. Do you suffer from lower back pain? *
11. What time would you hope to run/walk a 5km in? *
50 mins is an easy walk, 45 mins is a quick walk, 40 mins is a jog/walk, 35 mins is a jog, 30 mins is a run, 25 mins or less is a quick run. If you can do it in less than 23 just select 23 minutes
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