Last name

Middle name

First name

Mr.Ms.

Street and house number

Postal code

City

Phone number

Email address

How did you find us? (Multiple answers possible)

Through a friend or acquaintanceThrough a userThrough printed media, such as a newspaper or magazineThrough a Google searchThrough YouTubeThrough FacebookThrough LinkedInThrough Instagram

What type of condition do you have?

Spinal cord injuryStroke (CVA)MSAmputationParkinson’s disease

Have you previously tested one of our products?

YesNoNot sure

Other, namely:

What can you still do with your legs?
For example, standing on your right leg or walking 5 meters with crutches.

How is the gripping function of your hands?

Left normalRight normalLeft reduced but can still hold somethingRight reduced but can still hold somethingLeft noneRight none

Height in centimeters

Weight in kilograms

Date of birth

Which mobility aids do you use?

Rigid frame wheelchairFolding wheelchairElectric wheelchairMobility scooterWalkerCane or tripodCrutchesAttachable handbikeFixed-frame handbikeTricycleOtherNo mobility aids

Comments:

Would you like to receive our newsletter?

YesNo

Do you agree to BerkelBike B.V.’s cookie and privacy policy?
I agree to the cookie and privacy policy.

The following 5 questions are only for people with spinal cord injury.
If you do not have a spinal cord injury, scroll down and click "Send"

In what year did you sustain the spinal cord injury and how did it happen?

Level of spinal cord injury

If you were pricked with a pin in your buttocks or upper legs, what do you feel?

Clearly felt, sharp sensationFelt, but not sharpNot feltOther

Have you ever experienced spasms where the glute or thigh muscles were clearly active?

No, neverYes, but rarelyYes, regularly

Do you use anti-spasm medication?

NoBaclofenDantrolene (Dantrium)FampridineBotox injectionsOther

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