Plymouth CFS/ME Service

Referral Form

Address: Sentinel Clinical Assessment and Treatment Service, CFS/ME Service,Express Diagnostic & Treatment Centre, Plymouth Science Park, Plymouth, PL6 8BU

Tel: 01752 435205 Email:

Patient details
Name: …………………………….…………… DOB: …………………………………..
Address: …………………………………………………………………………...... ………
Postcode: ……………………………………… Telephone: …………………………….
Gender: Male □Female □
MANDATORY: NHS No ………………………………….
Referred by:
GP Name: ……………………………………..…….
Address: …..……………………………………………..………………………………………………
Postcode: ……………………………………………
Telephone: ……………….. ………………………..
Email: ………………..………………………………

Diagnosis

The expectation is that diagnosis is made at a primary care stage.Please refer to NICE guideline CG53 or the NEW Devon Joint Formulary forreferralcriteria.The Fukuda diagnosticcriteria which are more rigorous see below.

Summary of Fukuda Criteria for Diagnosis of CFS/ME

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Please tick where appropriate

Debilitating, persistent or relapsing fatigue for at least 6 months, not lifelong.
Not the result of ongoing exertion, not substantially alleviated by rest.
Severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities.
At least four of the following symptoms, persisted or recurred during 6 or more consecutive months of illness, did not predate the fatigue; Impaired memory or concentration, sore throat, tender lymph nodes, muscle pain, pain in several joints without swelling or redness, headache, unrefreshing sleep, feeling ill after exertion.
No clinical evidence of other causes of fatigue: 1) organ failure; 2) chronic infections; 3) rheumatic and chronic inflammatory disease; 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; 11) Psychiatric conditions.

1)Please describe below or attach a letter, any other relevant information, beyond clinical criteria, in your formulation towards diagnosis with the patient and therefore to referral.

2)Medical assessment can be provided on request for patients with a very complex or unclear diagnosis.

3)Medical history/other conditions.

*****Please attach current medication/patient profile*****

4)Are there any referrals to other services pending? If yes please state.

*****Please attach any relevant specialist reports/letters*****

5)Any other relevant information pertinent to attending the CFS/ME service.

Please note:

Nice recommends that the following blood tests should be performed in a timely manner for all patients referred to a CFS/ME service; FBC’s, Glucose, U&E’s, LFT bone chemistry, CK, TFT, Coeliac screen.

Please consider whether the following are appropriate to the individuals presentation; Hepatitis screen, Ferritin, B12, Folate, ANA.

We will assume from your required signature below that all bloods necessary have been performed and were normal.

GP Referrer Signature: …………………………………………Date: …………………

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