DeutschEnglishFrancaise
Home  | Contact  | Imprint  | Log-In

Dear customer,
You are interested in a Therapeutical exerciser. We would like to advise you ideally which THERA- or BALANCE-Trainer with necessary accessories is suitable for you. Please help us with your specifications. Return the completed questionnaire to us. Of course your statements will be kept in confidence.

First name:
Last name:
Street:
ZIP code / Place:  / 
Phone:
e-Mail:
Date of Birth:
Height in cm:
Weight in kg:
 
Disease patterns:
Multiple sclerosis
Paraplegia
Tetraplegia
Muscular disorders
Hemiplegia / Stroke
Rheumatic disorders / arthrosis
Joint replacement / TEP
Heart- / Cardiovascular disorders
Parkinson’s disease
 
Walking ability:
longer distances
Short distances
With sticks
Wheel chair
 
Spasm:
no
Mediocre
Strong
 
Symptoms:
Amyotrophia
Circulatory disorders / leg orders
Painful legs
Edema / water in the legs
Incontinence
Ankylosis
Sleep disorders
 
Recent therapy:
Physiotherapy
Miscellaneous:

Times per week,
Minutes each
 
Special remarks and wishes
My dealer::



Please enter the code above*: