Customer Discovery Form

Name:

Weight:

Age:

If Couple – who would benefit most from the Aqualift?

How long have you not been able to use your bath safely?

Have you had any bad experiences climbing in and out of the bath or shower?

What part of bathing do you find most challenging? Getting in or out?

What is your current solution for bathing?

Have you looked at or considered any other options?

Do you have any under floor heating?

What do you enjoy most about bathing?

Poor Circulation

Aches and Pains

Lack of joint mobility & Arthritis

Hip or Knee Replacement

Back Operation. Type?

Declining upper body strength

Low Blood Pressure/Dizziness

Poor Circulation (Mrs)

Aches and Pains (Mr)

Lack of joint mobility & Arthritis (Mr)

Hip or Knee Replacement (Mr)

Back Operation. Type (Mr)

Declining upper body strength (Mr)

Low Blood Pressure/Dizziness (Mr)

Poor Circulation (Mrs)

Aches and Pains (Mrs)

Hip or Knee Replacement (Mrs)

Lack of joint mobility & Arthritis (Mrs)

Back Operation. Type (Mrs)

Declining upper body strength (Mrs)

Low Blood Pressure/Dizziness (Mrs)

Advisor Name: