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Macmillan Activity Promotion Programme (MAPP) - Patient Self Referral Form
Date
Name
Male
Female
Address
Post Code
Telephone
(home)
GP Name
Date of
Birth
Telephone
(mobile)
GP Address
Do you / have you had a diagnosis of cancer?
Yes
Date of diagnosis
No
Please give details of your Cancer Diagnosis and Cancer Related Treatments
 Surgery
 Chemotherapy
 Radiotherapy
 Hormone Treatment
 Other
Do you have any other medical conditions? If so please state below.
Are you currently receiving any cancer
treatments
Please list any current medications
 Yes
 No
Details………………………………………………………………………
 Yes
 No
 Yes
 No
 GP
 Specialist Nurse
 Physiotherapist
 Other (please state)……………………………………
My preferred exercise location would be…………
 C&V (Whitchurch Rugby Club Tuesdays 2pm)
 Aneurin Bevan (time and dates)
 Cwm Taf (time and dates)
By completing this form I give consent for you to contact my GP etc.
Have you ever been told by your doctor that you
have a medical condition that means you cannot
participate in exercise?
Do you want to get more active to improve you
health and wellbeing?
I have discussed attending the MAPP scheme with
my healthcare professional
How did you hear about the MAPP scheme
Please send completed forms to: MAPP, Physiotherapy Department, Velindre Cancer Centre, Whitchurch, CF14 2TL
alternatively e-mail the completed form to: [email protected]
All individuals wishing to attend the MAPP scheme is required to attend an assessment session at Velindre Cancer
Centre, prior to joining the group. Appointment details will be sent in the post.
Macmillan Activity Promotion Programme (MAPP) - Patient Self Referral Form
What is MAPP?
This is a 12 week course run by a specialist physiotherapist which aims to improve your level of physical activity.
These are group sessions for people with cancer. You may be at any stage of your cancer journey from diagnosis
through to recovery or palliative care. If you want to be more active we will do what we can to help you.
Each session will be a 30 minute “well-being” discussion on six different topics and then you will complete a 45
minute physical activity session. The physical activity session will be tailored to your individual needs and we aim to
try and look at different types of activity each week to explore people’s different interests.
At the end of the course we hope you will feel more confident about physical activity and that you will carry on using
local services or doing activities on your own.
What happens now?
When we receive this referral form we will contact you with a date for an assessment. We aim that we will contact
you within 2 weeks.
Your assessment will take place at Velindre Cancer Centre, Whitchurch. This assessment will be completed by a
physiotherapist and will establish if MAPP is the best option to help you become more active.
If you are happy to start MAPP we will enrol you on a class within your local area for you to attend.
Do I need to bring anything?
As these sessions are designed to help you get more active we would encourage you to wear comfortable clothes
that are easy to move in.
We also ask that you wear flat shoes (trainers if possible).
You may also want to bring a cold drink and a warm top with you to wear after the session.
There is no charge for this class.
Please send completed forms to: MAPP, Physiotherapy Department, Velindre Cancer Centre, Whitchurch, CF14 2TL
alternatively e-mail the completed form to: [email protected]
All individuals wishing to attend the MAPP scheme is required to attend an assessment session at Velindre Cancer
Centre, prior to joining the group. Appointment details will be sent in the post.