Download Chronic Fatigue Syndrome

Sutton and St Helier Hospital CFS/ME Service Referral Form
This form is intended for GP’s to check the diagnosis of CFS/ME prior to referral. Please complete
all information and supply the required blood test results for your patient. Incomplete referrals will
be returned which will result in a delay to the patient receiving an appointment. If you are able
to confirm diagnosis on completion of the form, then your patient will be fast tracked into our
intervention options. If diagnosis is unclear, please indicate the reason in the relevant section and
your patient will then be offered an initial assessment appointment.
Date of referral …….…………
Patient’s Name
DOB
NHS Number
Address
Height
Occupation
Contact Number:
BMI
Weight
Patient’s GP Name
Address of Surgery
Name of referring GP (if different)
Onset of Fatigue:
(please circle as appropriate)
Practice Code
Surgery Telephone No:
Acute
Gradual
Viral symptoms: Yes
No
If this is a re-referral, please state your reasons for additional follow up.
Deterioration of patient’s condition (please specify)
Are you or the patient seeking additional management advice (please specify)
Other (Please specify)
Brief history of Fatigue:
G:\ Chronic Fatigue Referral form updated December 2015
1
Criteria for Diagnosis of Chronic Fatigue Syndrome
Debilitating persistent or relapsing fatigue for at least 4 months – but not life-long
YES/NO
Fatigue not the result of ongoing exertion and not substantially alleviated by rest
YES/NO
Fatigue severe enough to cause substantial reduction in previous levels of occupational,
educational, social or personal activities.
YES/NO
Plus At least 4 of the following symptoms persisted or recurred during 4 or more
consecutive months of illness and did not predate the fatigue:
YES/NO
Please also tick
which ones
apply
impaired memory or concentration;
sore throat, tender lymph nodes(symptom);
muscle pain/ pain in several joints without swelling or redness;
headaches – new or different from previous headaches
non-refreshing sleep;
feeling ill after exertion.
There is NO clinical evidence of other causes of fatigue
1) organ failure (eg. emphysema, cirrhosis, cardiac failure, chronic renal failure);
2) chronic infections;
3) rheumatic and chronic inflammatory diseases;
4) major neurological diseases;
5) systemic treatment for neoplasms;
6) untreated endocrine disease;
7) primary sleep disorders;
8) obesity (BMI>40);
9) alcohol/substance abuse;
10) reversible causes of fatigue such as medications, infections or recent major surgery;
11) psychiatric conditions (eg melancholic depression, bipolar disorder, psychoses, eating disorder
If any of the above, please attach any relevant information
TRUE/FALSE
Fulfils above Criteria for Chronic fatigue Syndrome
YES/NO
I confirm diagnosis of Chronic Fatigue Syndrome
and have discussed this with the patient
YES/NO
If NO please give details here
Severity of Fatigue
Mild
Moderate
Severe
Very severe
Mild 
Moderate 
Severe 
Very
Severe 
Mobile, self-caring, light domestic duties, may be working but to detriment of social, family and
leisure activities.
Reduced mobility, not working, reduced ADL, sleeping in daytime, peaks and troughs of
activity.
Few ADL, severe cognitive difficulties, wheelchair dependent for mobility, rarely leave house,
often significant worsening of symptoms with any mental or physical exertion
No ADL, bed-bound most of time, unable to tolerate any noise & are light sensitive, require
someone else to wash toilet and feed them.
G:\ Chronic Fatigue Referral form updated December 2015
2
Can the patient attend clinic? YES/NO (please circle)
If no then please telephone the service on 0208 296 4152 and speak to a member of the
clinical team before making the referral as we are not able to offer domiciliary visits.
Past Medical History / other
physical problems
Past Psychiatric History
(including any hx of
violence/aggression)
Patient’s present ability
E.g. Able to work, do
housework, cooking, self
care
Participation in leisure
activities?
Physical activity e.g. walking
- how far/how long?
Family History
Present Medication
(please attach printout)
Known Allergies
Other information (please complete or attach summaries / reports of relevant past medical history)
G:\ Chronic Fatigue Referral form updated December 2015
3
Blood Tests
Routine bloods investigations do NOT suggest a cause for fatigue



YES / NO
Please fill in ALL boxes with relevant results.
Attach results with form.
We will be unable to offer an appointment until ALL blood test results have been
received.
Full blood
count and ESR
Hb
Biochemistry
Autoantibodies
Immunology
TSH
Anti-nuclear
antibodies
IgG
WBC
U/E
Gastric parietal cell
antibodies
IgM
Platelets
LFT
Anti-mitochondrial
antibodies
IgA
ESR
CRP
Smooth muscle
antibodies
Immunoelectrophoresis
/paraproteins(not
required if under 35yrs)
Vitamin D
Anti-endomysial
abs/Coeliac
Screen/TTg abs
Please send this referral form to:
CFS Service
Sutton Hospital
Malvern Centre
Cotswold Rd
SUTTON
Surrey
SM2 5NF
Tel: 020 8296 3940
G:\ Chronic Fatigue Referral form updated December 2015
4