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Chronic fatigue / ME referral form

Patient details
The patient's full name
The patient's full address
The patient's home or mobile phone number

Brief history and severity of fatigue
Mild - Mobile, self caring, light domestic duties, may be working but to detriment of social, family and leisure activities. Moderate - Reduced mobility, not working, reduced activities of daily living (ADL), peaks and troughs of activity. Severe - Few ADL, severe cognitive difficulties, wheelchair dependent for mobility, rarely leaves the house. Very severe - No ADL, bed-bound most of the time, unable to tolerate any noise and light sensitive, require someone else to wash and feed them.

Please select an answer to all of the following statements

Which of the following symptoms persisted/recurred during 4 or more consecutive months and did not predate the fatigue (Please check yes or no)

Word finding problems, poor concentration ,memory issues

Indicate if the patient currently has any of the following medical conditions

Indicate if there is clinical evidence of the following conditions (please check box for all that apply and attach all relevant clinical information)
eg. emphysema, cardiac failure, chronic renal failure
eg. medications, infections or recent major surgery
**Long Term Mental Health conditions may mirror many aspects of CFS and therefore preclude CFS diagnosis
Please include clinical evidence of the checked conditions

The following blood tests need to be carried out prior to referral – please tick and attach results with form

Please attach any relevant blood test documents