Triage and Referral

Name: NHS Number:

Triage and Referral
Items underlined are required to enable admin staff to log the referral onto Lorenzo and meet Quality Indicators
Name of Team undertaking assessment:
Date of Referral: / Date Referral received (CFS use): / NHS Number
Name: including any previous names/aliases / Title: / Armed Forces: Yes /No
Address: Post Code:
Telephone Number:
Mobile Number: / Emergency Contact details:
Gender: / Date of Birth:
Age: / Religion:
Ethnicity / Marital Status / Accommodation Status
Spoken Language: / Overseas Status: Not Applicable / other
Preferred contact details i.e. mobile phone / Interpreter required: Yes / No
Name and contact details of referrer:
Address:
Tel Number:
Relationship or designation of referrer: / GP details, including practice [if not referrer]:
Tel Number:
Current support networks e.g. carer/neighbours/friends, significant other: / Does the person have a Lasting Power of Attorney: Yes / No
Does the person have an Advance Decision: Yes / No
Next of Kin details:
Tel Number / Current location of service user:
Dependants/Parental responsibility: Yes / No
Is the child living with the person: Yes / No
Legal: legal status / Care orders / In / recently in looked after system / police or court involvement / Do you have any concerns re capacity?
Yes / No / Is the person aware of the referral?
Yes / No
Current or previous involvement with mental health services: if yes give details / consultant / care coordinator 117 entitlements
Out of Area: Yes  No  / Are there any current safeguarding [child or adult issues Yes/No if yes please give details
School details if still in full time education / Employment status
Are you the patient’s GP? / Yes / No
Is the patient over 18 years? / Yes / No
A - Is the patient’s fatigue debilitating and persistent and:
Medically unexplained (not caused by conditions such as inflammation or chronic disease) / Yes / No
Onset of at least 6 months’ duration / Yes / No
Causing a substantial reduction in occupational, educational, social or personal activities / Yes / No
If answered no to any of the above, the person is not suitable for Chronic Fatigue Service
B – Please tick the patient’s symptoms in addition to fatigue
Self-reported problems with short-term memory or concentration / Yes / No
Frequent sore throat / Yes / No
Tender cervical or axillary glands / Yes / No
Muscle pain / Yes / No
Headaches of new type, pattern or severity / Yes / No
Un-refreshing sleep / Yes / No
Post-exertional malaise lasting more than 24 hours / Yes / No
Multi-joint pain without swelling or redness / Yes / No
Fewer than 3 symptoms ticked – the patient does not fit criteria for CFS.
If you have answered Yes to at least three of the questions above, have you excluded the following?
Established medical disorders known to cause Chronic Fatigue with appropriate blood tests / Yes / No
Major depressive illness with psychotic features (but not anxiety states, Somatisation disorder or non –psychotic depression) / Yes / No
Any medication which causes fatigue as a side-effect / Yes / No
Eating disorders, anorexia, bulimia or severe obesity / Yes / No

If you have answered no to any of the above, evidence suggests that organic or psychiatric cases may be a more likely cause and would ask that these are investigated further.
If you have excluded all of the above, the person is suitable for CFS , please complete referral form in full

Brief Clinical Summary, including any physical findings and current diagnoses:
Blood tests: please confirm results as being completed within the last 6 months and provide copies of the results with the referral
Full blood count / C- reactive protein / Auto-immune serology
Plasma viscosity / Blood sugar / Anti-nuclear factor
Biochemical profile / Thyroid function tests / Rheumatoid factor
Coeliac antibody
Current Medication
Social situation/Psychological history

Please send referral to:

The Team, Hull & East Yorkshire Chronic Fatigue Service, Department of Psychological Medicine, Clarendon House, Victoria House, Park Street, HULL HU2 8TD. Tel: 01482 617735

CFS Team use only

MDT discussion and rationale for actions
Outcome
Place on Joint Clinic waiting list 
Place on Therapist only waiting list (re-referral/previously established diagnosis) 
Request further information/incomplete referral 
No service required 
Consultant/Therapist: Designation/Band: Band:
Signature: Date: Time
Office use
Systems Checked / Y / N / Y / N
Lorenzo / Care First / Swift system
File Vision / Integrated Notes ordered
Medical notes ordered
SystmOne / NB – Crisis to be recorded as urgent on Lorenzo

Triage and Referral Form October 2012 (Review October 2013) Page 1 of 4