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Facial Pain Clinic The Eastman Dental Hospital
256 Gray’s Inn Road London
WC1X 8LD
Direct line: 020 3456 2300 Fax: 020 3456 2383
Email: [email protected]
Website: www.uclh.nhs.uk
LETTER OF REFERRAL TO FACIAL PAIN CLINIC
Name and Address of Referring Clinician Tel. No., Fax No., Email
Date: Patient Details Name: Date of birth: Address: Post Code: Telephone: Purpose of referral (please select as appropriate): Has a dental cause for the pain been excluded?
(Please note that the facial pain service only reviews patients who have had a dental cause for their symptoms excluded – please see
“guidelines for referral to the facial pain clinic” document on the website)
Has an ear nose and throat cause for the pain been excluded? (Facial pain associated with cardinal nasal (blockage, discharge) and /or ear (blockage, discharge, deafness, tinnitus, vertigo) symptoms
should be referred for an ENT opinion and have any such causes excluded prior to coming to the facial pain service)
Does the patient require an interpreter? If yes what language?: Provisional diagnosis / what has the patient been told: Duration of pain overall (date of first episode of this pain): Please check most appropriate: Pain is continuous with slight fluctuations in severity Pain is continuous with significant fluctuation of severity Pain attacks with episodes of no pain in between Site of pain and its radiation Please show on diagram
Any other sites of pain elsewhere on the body: Character (how the patient describes how the pain feels):
Right Left
Severity on a scale of 0 – 10 (10 most severe, 0 no pain): Current: Worst in last 4 weeks: Least in last 4 weeks: Provoking factors: Relieving factors: Any other associated factors: Current / Past treatments for pain: Medication Current
(yes/no) Dose Duration of
use Effective (yes/no)
Adverse effects
Other treatments (e.g. occlusal splints, dental restorations, endodontics, extraction, physiotherapy, osteopathy, alternative medicine, acupuncture, low intensity
laser, TENS, homeopathy, chiropractor, hypnosis) Please specify:
Previous consultations for pain (e.g. GP, oral surgeon, neurologist, physician, psychiatrist, ENT surgeon, neurosurgeon, psychologist, pain specialist, counsellor,
rheumatologist etc.) Please specify: Medical and psychological history – (please provide details if answer yes)
Previous operations / hospital admissions Cardiac / hypertension Respiratory Dermatological Diabetes / other endocrine Gastrointestinal Liver / Hepatitis Renal Musculoskeletal / other pains Neurological /migraines Mental health Allergy Other (please give details)
Please list the patient’s current medications:
Relevant family / social history that could influence pain and the patient’s ability to manage pain: Any other relevant details: Name of referring Clinician : Job title e.g. (Dentist / GP / Consultant) :
(Please note that referrals may not be accepted if they do not have adequate detail)
