Referral to the South Coast Fatigue Bespoke Severe CFS/ME Service

Name: DOB: Age:

Address:

GP Name and Address:

Referrers Name and Address, contact details:

Please consider the categories below when referring your patient for the ‘Bespoke Severe CFS/ME service’.

If your patient does not fulfil the criteria for severe or very severe then please contact us for further information on other services that we provide.

The severity of CFS/ME is divided into 4 main categories:

Mild – Are mobile and can care for themselves and can do light domestic tasks with difficulty. The

majority will still be working. However, in order to remain in work, they will have stopped all leisure

and social pursuits.

Moderate – Have reduced mobility and are restricted in all activities of daily living. They have usually

stopped work and require regular rest periods.

Severe – Will be able to carry out minimal daily tasks only, have severe cognitive difficulties and are

wheelchair dependent. These people are often unable to leave the house except on rare occasions.

Very severe – Will be unable to mobilize or carry out any daily tasks for themselves and are in bed for

the majority of the time. These people are often unable to tolerate any noise, and are generally

extremely sensitive to light.

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Referral is via GP or consultant only. Please complete this form and send an accompanying referral letter along with the Individual Funding Request (IFR) and screening test results to the Commissioning Team at your local PCT.

Please note there is no medical opinion in this service so diagnosis must be made prior to referral.

If patient <18 years please refer to Children’s services. Children age 16 and 17 in full time education should be referred to a Pediatrician or CMHT Services as appropriate first.

If patient > 65 please refer to old age medicine first

Is the fatigue: (all these criteria need to be met)

·  Medically unexplained (not caused by conditions such as inflammation or chronic disease)

·  Of definite new onset, but at least 4 months duration

·  Not due to ongoing exertion (e.g. shift work or over activity)

·  Characterised by post exertional malaise and /or fatigue

·  Causing a substantial reduction in occupational, educational, social or personal activities

In addition to the fatigue, are one or more of the following symptoms present? Please tick.

·  Difficulty with sleeping (insomnia, hypersomnia, unresfreshing sleep, disturbed sleep wake cycle)

·  Muscle and /or joint pain that is multi site and without evidence of inflammation

·  Headaches

·  Painful lymph nodes without pathological enlargement

·  Sore throat

·  Cognitive dysfunction (difficulty thinking, inability to concentrate, impairment of short term memory, difficulty with word finding/planning/organizing thoughts and information processing)

·  Physical or mental exertion makes symptoms worse

·  General malaise or flu like symptoms

·  Dizziness and /or nausea

·  Palpitations in the absence of identified cardiac pathology

Have you excluded the following?

·  Established medical disorders known to cause fatigue

·  Major depressive illness with psychotic features (but not anxiety states, somatisation disorder or non-psychotic depression). What services have been accessed to optimize their mental health? Please include copies of all correspondence from mental health services.

·  Any medication which causes fatigue as a side effect

·  Eating disorders, anorexia, bulimia or sever obesity (BMI >=45)

·  Alcohol or other substance abuse within 2 years before the onset of chronic fatigue or at any time afterwards

·  Red flag ‘features’:

Localising/focal neurological signs

Have you reliably excluded inflammatory arthritis or connective tissue disease?

Signs and symptoms of cardio respiratory disease

Significant weight loss

Sleep apnoea

Clinical significant lymphadenopathy

If ‘Yes’ to the above then please continue with your referral to South Coast Fatigue Ltd.

Please note that all blood tests must be carried out prior to referral and sent in with the referral documents.

If ‘NO’ to the above then evidence suggest that organic or psychiatric causes may be a more likely cause. Please investigate further.

Please reconsider the diagnosis if the person has none of the following:

·  Post exertional malaise

·  Cognitive difficulties

·  Sleep disturbance

·  Chronic pain

The patient is willing to have a bio-psychosocial assessment YES/NO (circle as appropriate)

Exclusion Criteria

·  Major psychiatric illness with psychotic or manic features

·  History of failed rehabilitation specific to CFS/ME (e.g. specialist CBT programme) unless there are specific reasons to reconsider the role of rehabilitation (please outline these in your referral letter)

·  Concurrent rehabilitation from another service

·  Ongoing medical investigation

What the service offers

Multidisciplinary assessment and bespoke domiciliary clinical intervention

Consultation and advice in liaison with primary care teams

Multi component bespoke rehabilitation package for symptom management

NB WE DO NOT OFFER LONG TERM COUNSELLING/SUPPORT

DUE TO OUR LARGE CATCHMENT AREA WE WILL PRIORTISE REFERRALS AND CAN ONLY ACCEPT THOSE THAT MEET OUR CRITERIA.

In some cases we will be expecting to advise other professionals regarding case management rather than accepting the referral ourselves.

Screening Tests

·  Urinalysis for protein, blood and glucose

·  Full Blood Count

·  Urea and electrolytes

·  Liver Function

·  Erythrocyte sedimentation rate or plasma viscosity

·  C-reactive protein

·  Random blood glucose

·  Screening tests for gluten sensitivity

·  Creatinine Kinase

·  Thyroid Function

·  Serum calcium

Please ensure that all results are within the last 6 months and accompany the referral documents.