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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