Download GP Referral Form - Salus Fatigue Foundation

TAKING POSITIVE STEPS TOGETHER
email: [email protected]
Salus Fatigue Foundation provides support, advice and education to people affected by CFS/ME/Fibromyalgia. The
diagnosis will generally already be established and other possible causes will have been excluded. Completion of
this form will help us to support your patient in developing a self-management approach to improve their health
and wellbeing.
ENTRY CRITERIA
Patient name, address, telephone number and email address
(Page 1 of 2)
Date of Birth
Has patient been given a
diagnosis of CFS/ME/Fibro?
YES/NO
Criteria for diagnosis of four months duration or more:
Pathologically sustained disabling fatigue (of definite onset, not life-long)
No clinical evidence of other cause
Neurological & cognitive problems – concentration/memory/information processing
Persistent sore throat
Tender cervical or axillary lymph nodes
Muscle pain
Pain in several joints without swelling or redness
Headache of a new type, pattern, or severity
Un-refreshing sleep
Post-exertion malaise lasting 24 hours or more
Autonomic nervous system problems – vasomotor/bowel or bladder dysfunction
Neuroendocrine system dysfunction, e.g. loss of thermostasis, emotional lability
Immune system dysfunction – recurrent infection, allergies, food intolerance
(tick)
Required blood tests:
Yes/No
Full blood count
ESR
CRP
Urea and electrolytes
Liver function test, PO4 Protein electrophoresis
Calcium
Random blood glucose
Creatine kinase
TSH, T4, free T3
Screening for coeliac disease (TTG)
Serum ferritin
Urinalysis for blood, sugar, protein
Other investigations carried out: (optional)
Antibody screening tests (e.g. hep B/C, Lyme disease etc.)
Autoimmune/rheumatology tests
Charity No: 1151924
TAKING POSITIVE STEPS TOGETHER
email: [email protected]
REFERRAL FORM
GP name
Surgery details
Does your patient need communication support?
YES/NO
(page 2 of 2)
Date of referral
Please state type of support/language
When completed, please pass this form to your patient and ask them to contact us by email or phone to discuss their
support needs. Patients are asked to bring the referral form with them to their first meeting with a member of our
team.
Dr Christine Lloyd BMBS MRCGP has worked closely with Salus since 2009 and helped to develop and validate this form.
Charity No: 1151924