Date of birth
Place of residence
Your Email (required)
Do you travel together with another person?
If yes, is this person valid?
Do you want to share a room with him or her?
Do you want a single room (extra payment)?
Please give a comprehensive definition of what you can do and what you can’t do:
For example, can you stand up, can you walk etc. etc
Do you have any visual restrictions?
Are you ADL(Activities of Daily Living) independent? In other words, are you able to manage your own personal hygiene like showering and going to the toilet?
Can you describe the kind of assistance you need?
Do you depend on a wheelchair, rollator, etc?
If yes, which one of those do you use?
If you use a hand driven wheelchair, can you handle it yourself?
Do you take any medicines?
If yes, please mention them
Are you on a special diet?
If yes, please describe your diet
Do you depend on nursing assistance?
If yes, please describe the assistance you need
If you have any additional information, which we might need, questions, remarks or whatever comes to mind, please mention them: