Download Norfolk and Suffolk CFS / ME Service

Norfolk and Suffolk ME / CFS Service
Norfolk and Suffolk ME / CFS Service
Herbert Matthes Block
Northgate Hospital
Northgate Street
Great Yarmouth
Norfolk
NR30 1BU
Tel:
Fax:
01493 809977
01493 809970
Referral Form
Name of Referrer (please print)
PCT in which the patient resides:
Signature of referrer:
Address of referrer:
Date of referral:
GP (if not referrer):
Patient’s name:
NHS No:
Patient’s address:
Hospital No:
Telephone Numbers
Daytime No:
Home No:
Date of Birth:
Mobile:
Does this patient have any special needs, eg
uses a wheelchair, has a hearing deficit,
English is not their first language? Please
specify.
Page 1 of 4
East Coast Community Healthcare CIC and Norfolk and Suffolk CFS / ME Service
Author:
Norfolk and Suffolk ME / CFS Service
File:
\\Dora\Documents\ME\Templates\ServiceLetterTemplates\ReferralForm.doc
Date:
December 2011
Version:
V4
Patients with ME / CFS exhibit some of the following symptoms:
Please indicate which are present:
Symptom
Present Comments
Y/N
Abnormal or intrusive fatigue for more than
6 months in an adult, or 3 months in a
young person
Impairment of memory and concentration
Post exertional malaise
Muscle pain
Unrefreshing sleep
Cervical / axillary lymphadenopathy –
often reported but less often detected on
examination
Recurrent sore throat
Multi-joint pain
New headaches
Failure to recover from an infection
(associated with onset in 75% of cases)
Any other relevant history, including any
history of mental health problems.
Page 2 of 4
East Coast Community Healthcare CIC and Norfolk and Suffolk CFS / ME Service
Author:
Norfolk and Suffolk ME / CFS Service
File:
\\Dora\Documents\ME\Templates\ServiceLetterTemplates\ReferralForm.doc
Date:
December 2011
Version:
V4
Basic blood screenings must have been carried out to exclude other causes of ME / CFS.
Please enclose copies of results for ALL of the following tests. Any omissions will result in a
delay in the processing of the referral.
 Urinalysis for protein, blood and glucose
 Full blood count
 Urea and electrolytes
 Liver function
 Thyroid function
 Erythrocyte sedimentation rate or plasma viscosity
 C-reactive protein
 Random blood glucose
 Serum creatinine
 Screening blood test for gluten sensitivity
 Serum calcium
 Creatine kinase
 Assessment of serum ferritin levels (children and young people only)
All tests should have been carried out within the last six months
Current Medication
Dosage
Page 3 of 4
East Coast Community Healthcare CIC and Norfolk and Suffolk CFS / ME Service
Author:
Norfolk and Suffolk ME / CFS Service
File:
\\Dora\Documents\ME\Templates\ServiceLetterTemplates\ReferralForm.doc
Date:
December 2011
Version:
V4
Previous Medication that has been tried
Dosage
Any further information that may be helpful.
(Please continue on a separate sheet if necessary)
Page 4 of 4
East Coast Community Healthcare CIC and Norfolk and Suffolk CFS / ME Service
Author:
Norfolk and Suffolk ME / CFS Service
File:
\\Dora\Documents\ME\Templates\ServiceLetterTemplates\ReferralForm.doc
Date:
December 2011
Version:
V4