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

When did you get the spinal cord injury?


How did you incur the spinal cord injury?


Beside the spinal cord injury, do you have another physical or mental disability?


At which height is your spinal cord injury?


Do you have any strength in your legs? If yes, which movements can you still make?


Can you feel a pinprick in your upper legs or bottom?


Did you have, since your spinal cord injury, any spasm by which your muscles contracted obviously? It does not matter if it has occurred years ago.


Which medication do you use and for what?


Can you open and close your hands?


Do you still have normal strength in your hands?


Do you have a hand cycle or have you ever ride one and how did it go?

Do you have a wheelchair? What kind: electrical wheelchair, foldable wheelchair, etc.

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.

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?