Criteria for Diagnosis of Four Months Duration Or More: (Please Tick)

The Adult CFS/ME Service is designed to offer evidence-based advice to sufferers. The diagnosis will generally already be established and other possible causes will have been excluded. Completion of this form will help us to plan service delivery to your patient.

PATIENT NAME, ADDRESS AND TELEPHONE NO. / DATE OF BIRTH / NHS NO. / HAS PATIENT BEEN GIVEN A DIAGNOSIS OF CFS/ME?
YES/NO
Recent medical history, including diagnosis of CFS/ME:
(please attach copies of all relevant reports)

Criteria for diagnosis of four months duration or more: (please tick)

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-exertional 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

Required blood tests: all tests must be completed for us to be able to process the referral.

Results / Date done
Full Blood Count
PV
CRP
Urea and electrolytes
Liver function tests, 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

REFERRAL FORM (page 2)

Other investigations carried out: (optional but desirable)

Results / Date done
Antibody screening tests (e.g. hep B/C, Lyme disease, etc.
Autoimmune/rheumatol tests

Other information: (please complete or attach summaries/reports of relevant past medical history)

Other physical problems
And co-morbidity
Family History
Mental health history
(If the patient has a mental health history, please attach reports and/or other relevant documentation) / Current Diagnosis
(Please tick) / Date of Diagnosis / Previous Diagnosis / From / To
None
Depression
Psychosis
Bi-polar
Anxiety
Other:
/ None
Depression
Psychosis
Bi-polar
Anxiety
Other:

Current Mental Health worker name and contact details:
Other relevant history, including therapies and treatments already received for CFS/ME
Please attach print-out of current medication.
Patient’s current employment position:
□ Currently employed full-time □ Currently employed part-time
□ Employment temporarily discontinued due to fatigue-related symptoms
□ Employment indefinitely discontinued due to fatigue-related symptoms
□ Other (please specify)
GP NAME / SURGERY DETAILS / DATE OF REFERRAL

Version 11 – Jan 2013 Page 2 of 2