Mobility Questionnaire

Each passenger in your party should complete and submit the following form

Title, First Name & Surname *

Email Address *

Date of Travel

Ship

Today's Date *

1. Do you need assistance to walk 300ft/100m? *

2. Do you use a walking stick/cane? *

3. Do you use a walker or rollator? *

4. Do you use crutches? *

5. Do you need assistance when walking on uneven surfaces (cobbles/grass/sand)? *

6. Do you use a wheelchair? *

7. Do you need assistance to ASCEND 2 flights of stairs (24 steps):- *

8. Do you need assistance to DESCEND 2 flights of stairs (24 steps)? *

9. Do you need assistance to negotiate up to a 6 inch kerb without a mobility device? *

10. Do you need assistance to negotiate ramps greater than 12.5% grade without railings? *

11. Do you need assistance to get off the floor unassisted? *

12. Do you need assistance to enter/exit a tender boat? *

13. Do you require oxygen? *

14. Can you get up from sitting unassisted 100% of the time? *

15. How many times have you fallen in the last 12 months? *

Please provide any further relevant information

Please read the following text carefully.

By completing this form, if I have answered YES to one or more of the questions numbered 1 to 13 I understand I may experience some difficulty on some aspects of my cruise/ports of call/shore excursions which have been explained to me/are shown below.

Please note this list is not exhaustive and we are happy to answer any questions you may have. 

CroisiEurope River Douro, Portugal Cruises
•	There is a lift/elevator available to all decks except the sun deck
•	Wheelchair accessible shore excursions are not available.  All excursions are via motorcoach with steps to entry (not low entry or “kneeling” coaches).  Some excursions may involve considerable walking and others may be panoramic tours where viewing of places of interest takes place from the coach (or a mixture of both).  The Reception desk onboard will be happy to advise you.  
•	The places you visit on your port calls may not be suitable for wheelchairs and may have cobbles or uneven surfaces.
•	Access on and off the ship is via a ramp, the gradient of which will alter according to the water levels.
•	Occasionally, the ship may dock alongside another ship where access to the shore will be through another vessel.
•	The ship and access on and off the ship is not suitable for full time wheelchair users.
•	Part time wheelchair users can take a wheelchair onboard for use on shore, the wheelchair must be stored in your cabin.
•	All cabins have telephones so you can call Reception or the Dialysis Team if required.


Celestyal Greek Island Cruises
•	There are lifts/elevators to all decks
•	Wheelchair accessible shore excursions are not available.  All excursions are via motorcoach with steps to entry (not low entry or “kneeling” coaches) .  Some excursions may involve considerable walking and others may be panoramic tours where viewing of places of interest takes place from the coach (or a mixture of both).  The shore excursion desk onboard will be happy to advise you.  
•	Please view the Celestyal shore excursion guides on our website for detailed information.
•	The places you visit on your port calls may not be suitable for wheelchairs and may have cobbles or uneven surfaces.
•	If you wish to explore independently, at your own pace, the reception staff onboard will be happy to arrange a taxi for you.
•	Access on and off the ship is via a ramp, the gradient of which will alter according to the tide levels.
•	Some ports are tender ports where you will be required to enter and exit a tender boat if you wish to go ashore.
•	Wheelchair accessible cabins for full time wheelchair users are available, subject to availability.
•	Part time wheelchair users can take a wheelchair onboard for use onboard and on shore, the wheelchair must be stored in your cabin.
•	All cabins have telephones so you can call Reception or the Dialysis Team if required.

I confirm the answers to the above questions are an accurate description of my ability.

If my answers to any of the above questions change between now and my cruise departure date I agree to advise Cruise Dialysis, in writing, immediately.

Signature *

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Thank you and your team for everything on our cruise. We enjoyed it and the dialysis was first class. And the social side with you all was a pleasure.
Mr J Evans
I would just like to place on record my appreciation for the wonderful service and attention I received on my dialysis cruise round the Greek Islands. I hope to book with you soon for another trip soon.
Mr J Redfern
Just a quick note to thank you, the Charge Nurse and the rest of the team, including the Doctor, for the wonderful cruise we just enjoyed. As usual everything went well and we look forward to seeing you again in the future.
Mr K Best
Just wanted to say thank you, the ladies really enjoyed their holiday in fact one was crying and did not want to come home. They had a great time. Thank you for your help and patience .
Ms J Mitchell
Thank you for planning an excellent holiday which we thoroughly enjoyed – wish it was for another 3 days. The dialysis worked very well as we were a bit apprehensive for the first time Celebrity was great, our first time.
Mrs N Rahim
Just a note to say how enjoyable the Rhine cruise was. The dialysis was both caring and sociable.
Mr R Ward
Just wanted to say many thanks for the Cruise. We had a fantastic time.
Mr P McGouran
“I do wish to thank you, the Charge Nurse and the rest of your dialysis team. You’re doing a great service to those in need of it and who are keen to travel at the same time. Your variety of ocean and river cruises gives all those who may be interested a wide choice of styles and destinations, while at the same time being able to rely on professional care and service in dialysis needs. Keep up the good work. Thank you once again”
Mr Dominic Yau
Cruise was wonderful. We loved the Europa2 and Dr. Westerman was a delight to have do our dialysis sessions.
Mrs S Pearl
We had a lovely holiday and have lots of pictures to remind us of where we went – they are on my screensaver already and are a very enjoyable reminder. As you know I love these holidays. I am really grateful that I could have a holiday while on dialysis – it is so lovely to get away from home for more than a night!
Mrs L Osborn
I’d just like to thank you and your professional Dialysis Team for making my first ever cruise experience so wonderful.  Starting from the time of booking, through the worst parts – waiting for the departure date to come around, right through until disembarkation.

The paperwork, though comprehensive was clear and easy for myself and my home clinic nurses to complete, and your advice on what to pack for the expectations of the cruise liner took that stress away.

It was good to meet everyone in your team and my compatriots for treatment so soon after embarkation and everything always felt like it was no problem and easily handled.  The dialysis team was totally professional at all times, but that was also complimented by their personalities which meant time on dialysis went quite quickly chatting etc. The Nephrologist was extremely thorough at all times but was also quite amusing in her own way. The Charge Nurse was a wealth of experience and definitely the glue bonding the team together and always available for everyone at all times. The two nurses providing support were effective team players and knew their stuff.

Being an accompanied cruise meant there was always someone about if you wanted a chat even on the excellent inclusive shore trips. It was good to see the planning that went in to arranging dialysis sessions around these activities and the team were always looking to be flexible on start stop times.

I will do this again in the future, need to save up a bit first, but would recommend it to anyone.  Thanks for a wonderful holiday.
Mr K Summerhayes
I wanted to tell you that it was a wonderful cruise and thank you for all the efforts you have had in respect to the dialyses. Everything was working at the full satisfaction.
Mr J Steinmann
Just a quick email to thank you very much for all your help with organising our Canary Island Cruise and dialysis on board for my mum. Everything ran smoothly and the dialysis staff were excellent, friendly, professional and a pleasure to meet. Hopefully we will be able to travel again using your excellent dialysis at sea service.
Ms C Sharratt
I want to let you know we really enjoyed the holiday, the ship was very good and the dialysis went well.
Mrs S Platt
I just wanted to send you an email and say THANK YOU so much for all your help with organising the cruise for my mum and me! Anoop had a really good time on the cruise. It was definitely an experience, we managed to go on the organised day trips and see new places. Many thanks once again, I really appreciate all the help you gave me.
Mrs A Chandhock
My father asked me to contact you upon his return from his recent cruise which we booked with you. He wanted me to pass on what a great trip he had and a fantastic break. On a personal note I would also like to thank you for your service throughout the booking and my endless enquiries.
S Lupton
Trip was great and dialysis team work excellently together. Nephrologist and Charge Nurse were top notch. Again thanks you did a great job.
Mr R Gray
We arrived home safe, well and happy. You might like to know we were delighted with the whole Cruise Dialysis adventure. Apart from the impressively competent and conscientious attention of the dialysis team we both very much enjoyed their company and hope to be able to have future involvement. Rae’s health stood up very well, and she came home better than for years.

The AmaWaterways river cruise itself was also a great pleasure, at just the right level of comfort, interest and variety without opulence. Just about everything was well suited to our needs and desires – as experienced travellers and critical customers. You would be welcome to let others who might be interested contact us in case they have any questions about customers’ experience with your system.
R Kennedy & R Bogner
Just returned from a fantastic cruise. Everything was excellent and dialysis was 1st class . Have no hesitation in recommending you to others. Thanks for all your help. Hope to book again as soon as unit allows. Thanks again.
Mrs E Adrain
Recently my husband and I were fortunate to holiday with AmaWaterways. It was ‘The Enchanting Rhine’ cruise travelling from Basel in Switzerland to Amsterdam. The whole holiday from start to finish was fantastic. The staff on-board couldn’t do enough to ensure we were well looked after. The food was lovely and plentiful. The excursions were very well organised and catered for everyone. My husband had dialysis on-board which was also very well organised and arranged so no excursions were missed. The medical team were lovely and looked after my husband well. I would thoroughly recommend this cruise and hope future travellers enjoy it as much as we did.
Mr & Mrs K Setchfield
Enchanting Rhine Cruise. This was our first cruise with AmaWaterways on Dialysis. Unbelievable staff with impeccable service and attention to every detail from beginning to the end of our cruise. Well organised excursions for all passengers from the very fit to those who needed a slower pace. The Dialysis team was amazing – professional, efficient, caring and friendly. Thank you Lisa for all your help and support. This cruise exceeded all our expectations.
Mr & Mrs M Coogan
“We had a wonderful cruise and having dialysis on board was not a problem it worked out for all the shore trips, I had the early morning session which gave us breakfast at normal time and the rest of the day to ourselves, would have no hesitation in recommending Dialysis at Sea.”
Mr I Dougall
“We returned from the Celebrity Eclipse cruise to the Western Med and wanted to let you know how smoothly the dialysis and arrangements on board went. The dialysis staff were so attentive and friendly with back up from the cruise staff. I appreciated being able to spend some time on shore whilst my husband was well looked after. Thank you for help and personal approach in coordinating the cruise arrangements.”
Mr & Mrs W Banner
“For someone who had never been on a Sea Cruise and also being a Dialysis patient this venture was viewed with excitement but also with some degree of trepidation and worry.- Well we are back and what’s more are already looking to plan the next one. All our fears and worries quickly evaporated. The dialysis ran seamlessly. The service provided by the caring and considerate staff and the facilities were second to none, in my opinion they were 6 star. Through out the whole journey everyone had the Can Do attitude. It was a holiday of a lifetime. Thank you Lisa for all your help and support. We will be back”
Mr B Porter
“We had a lovely time the trips at port were just long enough for us before we had to go back onboard for dialysis. The nurses were friendly and it was all really organised and relaxing. Thank you”.
Mrs R Thwaite
“We went on the 14 night Celebrity Eclipse cruise departing Southampton on 3rd September 2017 to Gibraltar, Lisbon etc and it was brilliant. Everything about the trip was superb. Without exception the staff was helpful, cheerful and friendly. The dialysis unit under Dr Dale was very efficient. Will definitely book another cruise with you from Southampton”.
Mr & Mrs D Tarrant
“An e-mail to say that we really enjoyed the Rhine cruise. The boat was good, the food nice, the company great. The dialysis went OK. Thank you for all the arrangements and making the holiday very enjoyable.”
Mr A Richardson
“Jack and I would like to thank you for organizing our very interesting holiday. The service from the start was amazing everything went according to plan and those who were supposed to meet us were there, it made the holiday for me. The staff on board Belvedere were always polite and pleasant. Jack was very happy with the way the dialysis was dealt with and the doctors and nurses were very professional. We look forward to having more holidays with you in the future.”
Mrs A Allen
“As my father cannot travel around for holidays easily and enjoys going abroad we decided to try a cruise. We would never have thought to take a wheel chair if it not been for your recommendation. Armed with a lightweight wheel chair for trips ashore we were on our way. Father was then able to go ashore even on treatment day, and save energy for pottering around the ship later in the day. The wheelchair has been a real boon, it features as a Zimmer frame and was so useful going round the airport, it has transformed our view on what is possible for holidays and day trips. Dialysis treatment on board is easy and is usually fitted in for time in port. All your booking is taken care of including treatment with medical reports sent by your unit. We have done several with another next year. It’s well worth a try.”
Miss Y Schofield
“First of all – thank you for all your help both before and during the cruise. We enjoyed it very much – the Belvedere was very comfortable and the food was good. We were also lucky with the weather – the only rain was at Nuremberg on the last day ! The dialysis sessions worked well also.”
Mr R Rowe