QUESTIONNAIRE

Family name(required)

Christian name(required)

Given name

Date of birth

Address

Area code

Country

Place of residence

Your Email (required)

Telephone number(required)

Skype name

Do you travel together with another person?

yes no 

If yes, is this person valid?
yes no 

Do you want to share a room with him or her?

Do you want a single room (extra payment)?
yes no 

ABILITIES AND DISABILITIES

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?
yes no 

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?
yes no 

Can you describe the kind of assistance you need?

SUPPORT

Do you depend on a wheelchair, rollator, etc?
yes no 

If yes, which one of those do you use?

If you use a hand driven wheelchair, can you handle it yourself?
yes no 

MEDICAL INFORMATION

Do you take any medicines?
yes no 

If yes, please mention them

Are you on a special diet?
yes no 

If yes, please describe your diet

Do you depend on nursing assistance?
yes no 

If yes, please describe the assistance you need

ADDITIONAL INFORMATION

If you have any additional information, which we might need, questions, remarks or whatever comes to mind, please mention them:

inspiring-handiholidays-slogan