Hillingdon CFS Service Referral Form

Referral Form

Patient’s Name / Referral
Date / Sex / M / F
Jade No / Ethnic Group
NHS Number / Date of Birth
Patient’s
Address
Telephone / Preferred language
Referring GP / GP Code
Surgery Address
Telephone/Fax / Email
Please indicate which Borough you are in:
Harrow / Hillingdon / Hammersmith & Fulham / Brent / Kens’ton, Chelsea & W’minster / Hounslow / Ealing

Reason for Referral, Medical & Psychiatric History

Please list reason for referral, any relevant medical & psychiatric history that is not clearly documented in attached correspondence, and any further information that would be helpful to us.
Please confirm that other medical causes of the symptoms have been investigated and excluded (e.g. organ failure, chronic infections, inflammatory/ neurological diseases, untreated endocrine diseases, primary sleep disorder, obesity (BMI>40), alcohol/ substance abuse, reversible causes of fatigue or psychiatric condition).

Medical Screening Information*

Please provide us with up-to-date results (past 3 months) for the following investigations, by filling in the form below. If these results are not available, please arrange for blood tests to be done prior to sending the referral. We cannot offer a medical screening without this information.
FBC / URINALYSIS
HB / (115-165) / Blood
PLT / (150-450) / Glucose
MCV / (76-98) / Protein
Neut / (2.0-7.0)
WBC / (4.0-11.0) / ESR(0-10)
U&E / Phosphate / (3.0-5.0 mg/dL or .97-1.61 mmol/L)
Sodium / (136-145)
Potassium / (3.5-5.1) /

Thyroid

Urea / (1.7-8.3) / TSH / (.5-5.0)
Creatinine / (44-80) / FT4 / (.58-1.65)
LFT / Calcium
Total bilirubin / (4-17) / Calcium
ALT / (10-36) / Corrected Calcium / (2.15-2.55)
ALP / (35-104)
Albumin / (34-48) / Coelic Serology
TTG
Random Glucose / (3.9-5.8)
Creatine Kinase
CK / (24-195)

*Normal ranges can vary according to the laboratory used. Please indicate any results you consider to be outside the normal range.

Please list any current medication & other treatments.

Thank you. We will confirm receipt of the referral as soon as possible.

Cfs Service Referral Form / Page 1 of 2