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Edmonton Symptom Assessment System

Edmonton Symptom Assessment System
Print/stamp name:
Asessed by (signature/credentials/ID#/date/time):
Completed by:   Patient   Family
 
Please circle the number that best describes your average symptom over the past 24 hours:
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 possible appetite
Best feeling or 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
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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