Download Referral to the South Coast Fatigue Bespoke Severe CFS/ME

South Coast Fatigue and Associates
Lancaster Court
8 Barnes Wallis Road
Fareham
Hampshire
PO15 5TU
Tel: 01489 668109/883295
Mobile: 07786446347
Email: [email protected]
www.southcoastfatigue.co.uk
Referral to the South Coast Fatigue Bespoke Severe CFS/ME Service
Name:
DOB:
Age:
Address:
GP Name and Address:
Referrers Name and Address, contact details:
Please consider the categories below when referring your patient for the ‘Bespoke Severe
CFS/ME service’.
If your patient does not fulfil the criteria for severe or very severe then please contact us for further
information on other services that we provide.
The severity of CFS/ME is divided into 4 main categories:
Mild – Are mobile and can care for themselves and can do light domestic tasks with difficulty. The
majority will still be working. However, in order to remain in work, they will have stopped all leisure
and social pursuits.
Moderate – Have reduced mobility and are restricted in all activities of daily living. They have usually
stopped work and require regular rest periods.
Severe – Will be able to carry out minimal daily tasks only, have severe cognitive difficulties and are
wheelchair dependent. These people are often unable to leave the house except on rare occasions.
Very severe – Will be unable to mobilize or carry out any daily tasks for themselves and are in bed for
the majority of the time. These people are often unable to tolerate any noise, and are generally
extremely sensitive to light.
Health Professions Council OT26662 | British Association of Occupational Therapists BT0208772
COTSS-IP | Member of the Vocational Rehabilitation Association -346 | BUPA Recognised
Professional Indemnity Insurance with Balens
Director: Frances L Hill | Registered Office: 17 Caspian Close, Whiteley, Fareham, Hampshire PO15 7BP and Registered in England No:07014787
-----------------------------------------------------------------------------------------Referral is via GP or consultant only. Please complete this form and send an accompanying referral letter
along with the Individual Funding Request (IFR) and screening test results to the Commissioning Team at
your local PCT.
Please note there is no medical opinion in this service so diagnosis must be made prior to referral.
If patient <18 years please refer to Children’s services. Children age 16 and 17 in full time education
should be referred to a Pediatrician or CMHT Services as appropriate first.
If patient > 65 please refer to old age medicine first
Is the fatigue: (all these criteria need to be met)
 Medically unexplained (not caused by conditions such as inflammation or chronic disease)
 Of definite new onset, but at least 4 months duration
 Not due to ongoing exertion (e.g. shift work or over activity)
 Characterised by post exertional malaise and /or fatigue
 Causing a substantial reduction in occupational, educational, social or personal activities
In addition to the fatigue, are one or more of the following symptoms present? Please tick.
 Difficulty with sleeping (insomnia, hypersomnia, unresfreshing sleep, disturbed sleep wake cycle)
 Muscle and /or joint pain that is multi site and without evidence of inflammation
 Headaches
 Painful lymph nodes without pathological enlargement
 Sore throat
 Cognitive dysfunction (difficulty thinking, inability to concentrate, impairment of short term
memory, difficulty with word finding/planning/organizing thoughts and information processing)
 Physical or mental exertion makes symptoms worse
 General malaise or flu like symptoms
 Dizziness and /or nausea
 Palpitations in the absence of identified cardiac pathology
Have you excluded the following?
 Established medical disorders known to cause fatigue
 Major depressive illness with psychotic features (but not anxiety states, somatisation disorder or
non-psychotic depression). What services have been accessed to optimize their mental
health? Please include copies of all correspondence from mental health services.
 Any medication which causes fatigue as a side effect
 Eating disorders, anorexia, bulimia or sever obesity (BMI >=45)
 Alcohol or other substance abuse within 2 years before the onset of chronic fatigue or at any time
afterwards
 Red flag ‘features’:
Localising/focal neurological signs
Have you reliably excluded inflammatory arthritis or connective tissue disease?
Signs and symptoms of cardio respiratory disease
Significant weight loss
Sleep apnoea
Clinical significant lymphadenopathy
If ‘Yes’ to the above then please continue with your referral to South Coast Fatigue Ltd.
Please note that all blood tests must be carried out prior to referral and sent in with the referral
documents.
If ‘NO’ to the above then evidence suggest that organic or psychiatric causes may be a more
likely cause. Please investigate further.
Please reconsider the diagnosis if the person has none of the following:
 Post exertional malaise
 Cognitive difficulties
 Sleep disturbance
 Chronic pain
The patient is willing to have a bio-psychosocial assessment YES/NO (circle as appropriate)
Exclusion Criteria
 Major psychiatric illness with psychotic or manic features
 History of failed rehabilitation specific to CFS/ME (e.g. specialist CBT programme) unless there are
specific reasons to reconsider the role of rehabilitation (please outline these in your referral letter)
 Concurrent rehabilitation from another service
 Ongoing medical investigation
What the service offers
Multidisciplinary assessment and bespoke domiciliary clinical intervention
Consultation and advice in liaison with primary care teams
Multi component bespoke rehabilitation package for symptom management
NB WE DO NOT OFFER LONG TERM COUNSELLING/SUPPORT
DUE TO OUR LARGE CATCHMENT AREA WE WILL PRIORTISE REFERRALS AND CAN ONLY ACCEPT
THOSE THAT MEET OUR CRITERIA.
In some cases we will be expecting to advise other professionals regarding case management rather than
accepting the referral ourselves.
Screening Tests
 Urinalysis for protein, blood and glucose
 Full Blood Count
 Urea and electrolytes
 Liver Function
 Erythrocyte sedimentation rate or plasma viscosity
 C-reactive protein
 Random blood glucose
 Screening tests for gluten sensitivity
 Creatinine Kinase
 Thyroid Function
 Serum calcium
Please ensure that all results are within the last 6 months and accompany the referral documents.