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Modified Edmonton Symptom Assessment Scale (ESAS-FS)

Modified Edmonton Symptom Assessment Scale (ESAS-FS)

Patient name:
Date:
Time:

Please circle the number that best describes your symptoms:
No pain	0	1	2	3	4	5	6	7	8	9	10	Worst pain
No fatigue	0	1	2	3	4	5	6	7	8	9	10	Worst fatigue
No nausea	0	1	2	3	4	5	6	7	8	9	10	Worst nausea
No depression	0	1	2	3	4	5	6	7	8	9	10	Worst depression
No anxiety	0	1	2	3	4	5	6	7	8	9	10	Worst anxiety
No drowsiness	0	1	2	3	4	5	6	7	8	9	10	Worst drowsiness
No shortness of breath	0	1	2	3	4	5	6	7	8	9	10	Worst shortness of breath
Best appetite	0	1	2	3	4	5	6	7	8	9	10	Worst appetite
Best feeling of wellbeing	0	1	2	3	4	5	6	7	8	9	10	Worst feeling of wellbeing
Best sleep	0	1	2	3	4	5	6	7	8	9	10	Worst sleep
No financial distress (Distress/suffering experienced secondary to financial issues)	0	1	2	3	4	5	6	7	8	9	10	Worst financial distress
No spiritual pain (Pain deep in your soul/being that is not physical)	0	1	2	3	4	5	6	7	8	9	10	Worst spiritual pain

Reference:

Delgado-Guay MO, Chisholm G, Williams J, et al. Frequency, intensity, and correlates of spiritual pain in advanced cancer patients assessed in a supportive/palliative care clinic. Palliat Support Care 2016; 14:341.

Originally published in: Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7:6.

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