Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

Ethnicity *

Contact Information

Email Address *

Phone

Diagnosis Information

Which do you have? *

Date of Diagnosis (approx) *

If you do not know the exact date, please choose a rough date

Relevant Experience

Current or previous professional role:

Current or previous role within the charity – if applicable

Any other relevant experience you think would be beneficial to this role

Please could you explain why you would like to become a Buddy?

Personal WM/LPL Experience

Current Treatment *Active Monitoring (Watch and Wait)BR (Bendamustine / Rituximab)DRC (Dexamethasone/Rituximab /Cyclophosphamide)IbrutinibZanubrutinibStem cell transplantClinical TrialOtherPlease tick which treatment you are *currently* recieving:

More Info about your current clinical trial or other treatment

Treatment Start Date (approx) *

Date you started your current treatment. If you do not know the exact date, please choose a rough date.

Have you had a follow up appointment? *YesNoSince starting your treatment, have you had at least one follow up appointment with your haematology team, and been deemed clinically stable?

Previous Treatment(s) *Active Monitoring (Watch and Wait)BR (Bendamustine / Rituximab)DRC (Dexamethasone/Rituximab /Cyclophosphamide)IbrutinibZanubrutinibStem cell transplantClinical TrialOtherPlease tick which treatment(s) you have *previously* received:

Other treatmentsplease give a brief description of any other treatments for WM you have received in the past

Symptoms or Side Effects *NoneAnaemiaNauseaInfectionsFatiguePeripheral NeuropathyHair lossSkin changes (e.g. dryness/rashes)Please tick any of the symptoms/side effects you have experienced (either currently or previously) and would be open to discussing as a Buddy:

Other symptoms/side effects you would be open to discussing:

Associated Conditions: *AmyloidosisBing Neel SyndromeCold Agglutinin DiseaseCryoglobulinaemiaHyperviscosity SyndromePeripheral NeuropathyTransformation to a higher-grade LymphomaNone of thesePlease tick the below boxes if you have experienced any of the following and are open to discussing as a Buddy

Complementary Therapies *YesNoHave you received any complementary therapies for your WM/LPL? e.g. acupuncture, massage, reflexology

Which complementary therapies:Which complementary therapies have you received for your WM/LPL

Social Experience

Has your WM/LPL impacted any of the following? *Family lifeCaring for childrenEmploymentCoping with uncertainty/worries about the futureSomething else?None*Please note - We understand that these are very personal, so please only select options which you are open to discussing with a Buddy.

Is there anything else you would be open to discussing:

WMUK Buddy Service

Sometimes speaking to others who have similar WM experiences can be a helpful way to better understand your diagnosis, get advice from someone who has been through the same thing, or simply help you feel less alone.

Can you be a WMUK Buddy?

If you’re looking for peer support...

WMUK Buddy Application Form