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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.