Download Appendix C: Edmonton Symptom Assessment System

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Appendix C: Edmonton Symptom Assessment System
Edmonton Symptom Assessment System:
(revised version) (ESAS-R)
Please circle the number that best describes how you feel NOW:
No Pain
¬
¬
¬
¬
¬
¬
¬
¬
¬
¬ 10
¬
Worst Possible
Pain
No Tiredness
0¬
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10
¬
Worst Possible
Tiredness
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Drowsiness
(Tiredness = lack of energy)
No Drowsiness
0¬
(Drowsiness = feeling sleepy)
No Nausea
0¬
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Nausea
No Lack of
Appetite
0¬
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Lack of Appetite
No Shortness
of Breath
0¬
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Shortness of Breath
No Depression
0¬
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Depression
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Anxiety
1¬
¬
¬
¬
¬
¬
¬
¬
¬ 10¬
Worst Possible
Wellbeing
No __________ 0¬
1¬ ¬ ¬
Other Problem (for example constipation)
¬
¬
¬
¬
¬
¬ 10
¬
Worst Possible
_______________
(Depression = feeling sad)
No Anxiety
0¬
(Anxiety = feeling nervous)
Best Wellbeing
0¬
(Wellbeing = how you feel overall)
Completed by (check one):
Patient
Family caregiver
Time ______________________
Health care professional caregiver
Caregiver-assisted
Patient’s Name __________________________________________
Date _____________________
ESAS-r
Revised: November 2010
BODY DIAGRAM ON REVERSE SIDE
BCGuidelines.ca: Palliative Care for the Patient with Incurable Cancer or Advanced Disease Part 1: Approach to Care: Appendix C (2017)
1
Please mark on these pictures where it is that you hurt:
2
BCGuidelines.ca: Palliative Care for the Patient with Incurable Cancer or Advanced Disease Part 1: Approach to Care: Appendix C (2017)