Information
https://www.breastcancercare.org.uk/information-support/have-i-got-breast-cancer/benign-breast-conditions/breast-pain 
https://www.nhs.uk/conditions/breast-pain/ 
https://www.nhs.uk/common-health-questions/mens-health/what-is-gynaecomastia/#MC3275318/ 

Information
https://www.breastcancercare.org.uk/information-support/have-i-got-breast-cancer/benign-breast-conditions/breast-pain
https://www.nhs.uk/conditions/breast-pain/
https://www.nhs.uk/common-health-questions/mens-health/what-is-gynaecomastia/#MC3275318/

NCL Breast Pain Referral Form
Please refer via the e-Referral Service

Referring GP	Current User 	
Date of GP decision to refer	Short date letter merged 	
		
Patient Details:

Patient Name	Given Name Surname 	
Address	Home Full Address (single line) 	
DOB	Date of Birth 	NHS No.	NHS Number 	
Home Tel. No.	Patient Home Telephone 	Gender	Gender(full) 	
Mobile Tel. No.	Patient Mobile Telephone 	Ethnicity	Ethnic Origin 	
Preferred Tel. No.	Patient Mobile Telephone 	Email Address	Patient E-mail Address 	

Main Spoken Language	Main Language      	Interpreter needed? 	Yes      No   	
Transport needed?	Yes              No   	
Communication requirements:	Hard of hearing:       Visually Impaired:     Learning/Mental Difficulties: 	

Registered GP Details:
Practice Name	Usual GP Organisation Name 	
Registered GP	Usual GP Full Name 	Usual GP	Usual GP Full Name 	
Registered GP Address	Usual GP Full Address (single line) 	
Tel No.	Usual GP Phone Number 	Fax No.	Usual GP Fax Number 	
Email	Organisation E-mail Address 	Practice Code	Usual GP Organisation National Practice Code 	
	
Please advise the patient that they will be seen by the RFL breast team following the agreed NCL breast pain pathway, which doesn’t include imaging tests		
Number of times you have seen the patient for breast pain 		
Length of time you have seen the patient for breast pain 		
Breast Pain Clinic to be referred to	Royal Free London Hospital, Finchley Memorial Site		
If required, please state where patient should be referred to for:	Urgent suspected cancer breast clinic:		Family history clinic:		
Inclusion criteria
•	Patient has breast pain  
•	Patient has no other breast and axilla related signs or symptoms (e.g. lumps, nipple discharge) 
•	Minimum age is 16

Exclusion criteria
•	Any clinical signs requiring a referral to an urgent suspected cancer breast clinic
•	Past personal medical history of breast cancer 
•	Patient has implants
•	Male patients
•	Pregnant patients
•	Patient has a genetic predisposition for breast cancer	
Presenting symptoms
	
Family history of breast or ovarian cancer
Single Code Entry: Family history of breast cancer  	

Significant medical history                     Yes       No  
If Yes please state
Problems 	

Examination
Consultations 	
Relevant investigations
Values and Investigations 	
Comorbidities
Single Code Entry: Co-morbid conditions  	

Medications 	                          Yes       No  
If Yes please state
Medication 	

Allergies
Allergies