DERBY HOSPITALS NHS FOUNDATION TRUST
CHRONIC FATIGUE SYNDROME/ME SERVICE
Referral Form
PATIENT DETAILS
Name:
Address:
PRACTICE DETAILS
DoB:
Phone:
NHS number:
Doctor completing form:
Please attach a referral letter providing further information regarding current history, symptoms,
examination findings, previous or concurrent psychiatric illness, alcohol or unprescribed drugs/
medications, past medical history, current prescribed medication, social situation and employment. If
this is a re-referral, please state the reasons.
How confident are you of the diagnosis of Chronic Fatigue Syndrome/ME?
Not very
Reasonably
Very
Does the patient agree with the diagnosis?
Yes
No
Note: We do not provide a diagnostic service for medically unexplained fatigue. For guidance
on the diagnosis of CFS/ME please go to www.mapofmedicine.com (click on ‘access the map’
‘Chronic Fatigue Syndrome/ME care map’) or refer to the NICE guidelines on CFS/ME.
Which of the following best describes the primary reason for referral?
(Please tick all the boxes that apply)
The patient is seeking help with management of symptoms and disabilities
You or the patient are seeking a ‘second’ opinion / specialist confirmation of the diagnosis
You would like advice on medical management
The following tests must have been completed within the last 6 months. The results of these
must be provided in order for the referral to be accepted.
Date Details of results
Full blood count
ESR
CRP
U&E
LFT’s
Urinalysis for protein blood and glucose.
Thyroid Function tests
Random glucose
Coeliac Serology
Calcium and phosphate
Serum Creatinine
Creatine Kinase
Please inform us of any other investigations indicated by presentation and their results e.g. ferritin,
Vitamin D, plasma viscosity, rheumatoid factor.
When did the current episode of symptoms/disabilities begin?
Have there been previous episodes:
Derby LMDT/CFS GP referral form
29th November 2012 V3
Yes
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No
If yes, when?
DERBY HOSPITALS NHS FOUNDATION TRUST
What is the patient’s BMI?
(A BMI over 40 may preclude the diagnosis of CFS/ME).
Please give details of previous specialist medical assessments of the current symptoms and the
results of investigations
What other services have been involved in treatment? e.g. IAPT, physiotherapy (please provide
details).
Has the patient been suffering from debilitating persistent or relapsing fatigue for at least 4 months?
Yes
No
Is fatigue the primary complaint?
Yes
No If no please reconsider the appropriateness of this referral
Does the patient have fatigue that is not the result of ongoing exertion?
Yes
No
Does the patient have fatigue that is not substantially alleviated by rest?
Yes
No
Does the fatigue cause substantial reduction in previous levels of occupational, educational, social
or personal activities?
Yes
No
Please tick the patient’s symptoms in addition to fatigue that have persisted or recurred
during 4 or more consecutive months of illness and did not predate the fatigue.
Sleep disturbance including unrefreshing sleep
Muscle pain
Joint pain
Frequent sore throat
Headaches of new type, pattern or severity
Painful lymph nodes without pathological enlargement
Cognitive dysfunction
Post exertional malaise
General malaise or flu like symptoms
Dizziness
Nausea
Palpitations in the absence of identified cardiac pathology
Other (please state)
Can the fatigue be attributed to any other cause?
Yes
No
Please confirm that there is no clinical evidence of any other physical or psychiatric condition which
could be the main cause of the fatigue. (If unsure, please comment in your referral letter)
Signature:
Derby LMDT/CFS GP referral form
29th November 2012 V3
Date:
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