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 or mobility scooter? *

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? *

16. Which mobility devices will you be taking with you? (if none, please type NONE) *

Can the dialysis patient walk from the door of the cabin to the bed in the dialysis unit?

Yes the dialysis patient can walk to the bed

No the dialysis patient cannot walk to the bed

I am not a dialysis patient

Does the patient require assistance to get on and off the bed in the dialysis unit?

I do not require assistance to get on and off the bed

I do require assistance to get on and off the bed

I am not a dialysis patient

Please provide any further relevant information

Please read the following text carefully.

By completing this form, if I have answered YES or I CANNOT WALK 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. 


Ambassador Cruise Line
Please note that the ships’ crew are not required to lift guests or push wheelchairs. Guests may have to walk down/up steps and ramps without a walker or wheelchair when boarding/disembarking in ports of call, as local gangways/ramps may not always be wide enough to accommodate mobility devices.  All guests who wish to use a mobility device onboard the vessel, must occupy a Disabled cabin. They will be required to store mobility devices in their cabin and will not be permitted to leave them outside in corridors and stairwells or have them stored elsewhere on board. Each mobility device must not weigh more than 45kgs in total and must not exceed 75cm in width. Due to health and safety regulations, wheelchairs and scooters weighing more than 45kg cannot be taken ashore in any port of call, unless there's access via an air bridge or the mobility device can be dismantled. Each individual component of the mobility device must not weigh more than 25kg. Whilst the crew may be able to assist, it is ultimately the responsibility of your able-bodied companion to manage the mobility device when embarking and disembarking the vessel.

In addition to this, Ambassador also welcomes guests who wish to bring a lightweight wheelchair/scooter with them for shore use only however, these must be stored in your cabin at all times and cannot be used onboard the vessel in any circumstance.  You will be responsible for taking the wheelchair on and off the ship at each port of call. You must inform us at the time of booking if you would like to take a wheelchair onboard for shore use only.

•	There is a lift/elevator available 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 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.
•	Some ports of call may be accessible by a smaller tender boat.  Tenders are not suitable for full time wheelchair users or those with restricted mobility.
•	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.


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 *

“I want to say thankyou to you and John for making my first cruise so memorable and being so warm and supportive.”
Mr G Hinkins
We wanted to let you know how much we enjoyed our first Dialysis Cruise. It was so lovely to meet you and we really appreciated everything you arranged for us to make the experience run smoothly from the early days of booking the cruise to the dialysis on board. Peter and I were always confident that he was in safe hands and having excellent care throughout the cruise really made the holiday. A special “big thank you” to you and the Charge Nurse. We are so looking forward to our next cruise with you in December.
Mrs A Terrey
It was really great meeting yourself and the Dialysis Team and THANK YOU
all for making my dream of a holiday to Norway a Reality, especially with the
reassurance of very competent dialysis while on holiday. I look forward to my future trips with Cruise Dialysis.
Michael Williams
Cruise with Confidence. Cruise Dialysis was discovered on the internet. My first impression of Lisa Parnell encouraged me to sign up for a cruise. Naturally there were concerns with trusting one’s health with an unknown dialysis team. They were quickly overcome when meeting the Head Nurse, a dedicated nephrologist and team of nurses. They were all accomplished professionals and friendly as well. Two examples of why they are so good: their concerns about individual patients and willingness to be flexible in scheduling. Most importantly sessions were worked around ports so that cruisers had maximum access to shore activities. Additionally, they made efforts to know their patients, their preferences, and alter treatment times with passenger preferences in mind. There will be more cruises in my future with Ambassador Cruise Lines and their dialysis team. My family is confident that my health needs will be in good hands.
Steve Martin
This is my review of the German Market cruise last week (December), I really enjoyed it, met a lot of friendly people, food was good most of the time, nice warm Cabin, good entertainment, safe parking while away and the dialysis was first class, very caring staff and a special mention to the Charge Nurse and Lisa, pleasure to meet them, they made it all go smoothly, I would do it again probably in warmer weather, but for a first cruise, loved it and would recommend to others.
Paul Salmons
Just to say once again, thank you for the excellent organisation of our recent cruise. It went like a dream. My mum is 79 years old and has wanted to go on a cruise for many years. When she became ill and needed kidney dialysis (haemodialysis) we thought she would never fulfill her dream. I then discovered Cruise Dialysis, where kidney patients have their usual dialysis, on board ship, whilst on their holiday cruise. We looked at cruises offering dialysis at sea, and when we found the right one we wanted we booked it. Lisa at Cruise Dialysis was so helpful every step of the way, liaising with mum’s dialysis unit at home and helping us through the process.

The cruise on Ambience, one of Ambassador’s two ships, was fantastic. The ship is beautiful, the staff so lovely, and the dialysis team were absolutely wonderful. Mum was very much looked after throughout the whole 15 night cruise. She even danced several times, something she hasn’t felt well enough to do in years.

A huge thank you to all. Now she wants to go again!
Deborah Shellcock
I’d like to thank you for the wonderful service you provide for dialysis patients. The administration before the cruise was efficient and the care on ship superlative. I was very impressed with the clinical team and felt really confident with their level of expertise and experience. The dialysis sessions ran smoothly and contributed to a relaxing and reinvigorating holiday. We look forward to joining you for another cruise in the near future.
Andrew Westlake
I just wanted to say how great the cruise was. The facilities on board were above and beyond what Mark and I were expecting. Nothing was too much trouble for the crew members.

As for the dialysis, we’ll what can I say? Lisa; the Charge Nurse and his team were amazing! The care they gave to all the patients was fantastic – they all made us feel special and really looked after us.

I have to admit I was pretty nervous about dialysing on a boat with strange people but about 10 minutes after meeting the team it was as if we’d been friends forever!

The welcome speech given by Lisa and the Charge Nurse really put everyone at ease and it was a great opportunity to ask any questions.

I would say to anyone who feels like they can’t go on holiday because of being on dialysis to just get in touch with Cruise Dialysis and see the world open up again.

We are already planning next year’s holiday – a river cruise along the Danube. I think we’re hooked now!!

We’ll see you again soon.
Kim Fountain
Apologies for a very overdue message – an extremely busy spell for me with a new job starting and moving house – but we both wanted to say a huge thank you for making our time on board absolutely fantastic. We really appreciate the hard work and care put into making our trip so special, and many thanks too to all the team (not just for adopting me!). We hope to come back sometime in the future.
Antonia Coleman-Harvey
Just a belated note to say thank you and your staff for making the cruise so enjoyable.  The treatment and attention were first class, and I would certainly recommend to anyone thinking of Cruising.

As a Widower, Dialysis patient, and first time Cruiser I was very apprehensive about booking a cruise.

From the outset Lisa was extremely helpful and made the whole process easy, alleviating many of my concerns.  The paperwork was very easy to follow and my dialysis unit very helpful in ensuring all tests etc were completed.

Once on board we met the Charge Nurse and his team. The Charge Nurse’s enthusiasm for dialysis was remarkable explaining every detail with great clarity.  The treatment was as good as any private hospital.

Being single status was not an issue as I met several friendly people including the nursing staff (on their day off) for dining and in the bar.

Any Dialysis patient out there considering a cruise – take the plunge- I can thoroughly recommend it.
Graham Curtis
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