Referral Form

Personal details



Contact details (please give at least one)

Able to use for contact?

Able to use for contact?

Able to use for contact?

Able to use for contact?

GP details

Carer details (if applicable)

Can we contact your carer in an emergency or if we are unable to contact you?

Ethnic Group

Information about your health problems

Approximately how long have you been experiencing problems with your health?

Was there a specific trigger to your problems?

If yes, please give further details

What are your main symptoms are the moment? (tick all that apply)

Other / further details

Do you have other medical problems? (tick all that apply)

Other / further details

Current weight
Stones lbs or kilograms

Current Height
Feet inches or cms

Investigations and Treatment

There are many common causes of fatigue that can be treated by your GP. It is important that you have had all the relevant blood tests and that either the tests have been within normal range or any abnormalities have been adequately treated before attending.

If possible ask your GP for a copy of your test results and bring these to your assessment.

These routine investigations include (as recommended by the NICE Guidelines)

  • Full blood count
  • U&Es
  • Coeliac serology
  • ESR
  • Urine analysis
  • CRP
  • Calcium
  • Liver function test
  • Phosphate
  • Thyroid function
  • Random glucose

I confirm that all the investigations listed have been completed and were normal

or the following problems were identified in my tests and I received the following treatment for these:

Current medication (drug name) and dose

In the last five years have you received hospital treatment or undergone surgery or other therapies for any reason?

If yes give details and say if any are on-going problems

Any other information you feel is relevant to your referral


Medical assessment: Yorkshire Fatigue Clinic offers medical assessment for those patients who feel they require medical diagnosis. This may be offered at the clinic or at the Spire Hospital, Leeds.

Therapy Assessment: If you already have a provisional diagnosis from your GP or other medical practitioner and would like confirmation of this, this can be done by the Specialist Therapist. Therapy assessment will also include a formulation of your needs and progression onto therapy.

Contact us if you are unsure which assessment would best suit your needs.

I would like to request:

Funding (please tick which applies)

I will be self funding my assessment and treatment with the Yorkshire Fatigue Clinic
My GP is requesting NHS funding through my local commissioning group


I have read and accept the Terms and Conditions

After receiving your completed referral form we will contact you to arrange a convenient time for your assessment. If you have any queries please contact us to discuss these further.

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