Name
Gender (please tick)
Address
Email Address
Telephone Number
Emergency Contact
Forename
Section 1 - PARTICIPANT INFORMATION
Surname
Male
Town / City
Post Code
Home
Name
Mobile
Telephone
Female
Section 2 - MEDICAL CONDITION
Cancer Type
Date of Diagnosis
Treatment
Other Medical Condition(s)
Please provide an overview of your treatment to date and / or any treatment has been planned:
Please provide details in relation to any other medical condition(s) that you currently have, or have had in the past:
Section 3 - REFERRAL INFORMATION
Did you receive a referral to this service from a healthcare professional?
Pleas tick ‘yes’ or ‘no’
Yes
No
If you have ticked ‘yes’, please provide contact details for the healthcare professional that referred you to this service:
Name
Forename
Surname
Position / Job Title
Email Address
Telephone Number
If you have ticked ‘no’, how did you hear about this service?
Section 4 - DECLARATION
I agree to my information being passed on to Move More Ards & North Down, and agree to being contacted by the Macmillan
Move More Coordinator. I acknowledge that all information will be treated as confidential.
Name
Signature
Date
Please return completed forms to Eimear Hagan (Move More Ards & North Down) at:
Northern Community Leisure Trust, 3 Valentine Road, Bangor, BT20 4TH