Ask The Exercise Physioligist!

Name:
Address:
Zip code:
Place of residence:
Country:
Email address:
Telephone number:
Health insurance company:
Birth date:
Length (approximately):
Weight (approximately):

What is your disability?

When did you incur this disability?

Where do you want to cycle?
 I only want to cycle outside. (Skip next question). I want to be able to cycle outside and inside, by using my bike easily as a cycle trainer. I only want to cycle inside on my cycle trainer.

What kind of cycle trainer do you want?
 As simple as possible: I want to concentrate on cycling or for instance I want to watch the television. I enjoy it, when my rollertrack can be connected to the computer and has many possibilities like riding in South Africa with video images or cycling against opponents with virtual reality, where real cycling is imitated.

Is your disorder progressive (becomes the disability worse in the course of time)?
 Yes No

How high can you lift your left hand?
 Not Belly button height Shoulder height Above the head

How high can you lift your right hand?
 Not Belly button height Shoulder height Above the head

Can you grasp a glass of water with your left hand and lift it from the table?
 No Can grasp, not lift Can lift it, but not up to the mouth Can lift it up to the mouth

Can you grasp a glass of water with your right hand and lift it from the table?
 No Can grasp, not lift Can lift it, but not up to the mouth Can lift it up to the mouth

Can you stretch your left arm completely?
 No Almost Yes

Can you stretch your right arm completely?
 No Almost Yes

Does it hurt, when somebody else moves your left arm?
 No A little Yes

Does it hurt, when somebody else moves your right arm?
 No A little Yes

Can you walk?
 No With help of a companion With a walking trolley With crutches Yes, without any device, but only inside Yes, without any device outside, but less than 100 meters Yes, without any device outside, more than 100 meters

How many strength do you have in your left leg?
 None I can move my leg a little I can stand on it Not changed by my disability

How many strength do you have in your right leg?
 None I can move my leg a little I can stand on it Not changed by my disability

Can you pull your left leg towards yourself?
 No, and if somebody else tries to do it, it hurts or my leg blocks No, not by myself, but somebody else can bend my leg Yes, a little myself, with help completely Yes

Can you pull your right leg towards yourself?
 No, and if somebody else tries to do it, it hurts or my leg blocks No, not by myself, but somebody else can bend my leg Yes, a little myself, with help completely Yes

Do see objects on your left of right side equally good?
 No, at one side I can (almost) see nothing No, at one side I see a little bit less I see objects on my left or right side equally good

Can you have a conversation by phone?
 No Yes, with many difficulties Yes, but not like before Yes, without any problems

Did you have contact with somebody of BerkelBike BV before? If yes, in what way?

Do you want to tell anything, you did not get the chance to in the questionnaire?