Transcription of Edmonton Symptom Assessment System Revised (ESAS-r) …
1 Edmonton Symptom Assessment System Revised (ESAS-r)07903(Rev2015-08) No Pain012345678910 worst Possible PainNo Tiredness012345678910 worst Possible Tiredness(Tiredness = lack of energy)No Drowsiness012345678910 worst Possible Drowsiness(Drowsiness = feeling sleepy)No Nausea012345678910 worst Possible NauseaNo Lack of Appetite012345678910 worst Possible Lack of AppetitieNo Shortness of Breath012345678910 worst Possible Shortness of BreathNo Depression012345678910 worst Possible Depression(Depression = feeling sad)No Anxiety012345678910 worst Possible Anxiety(Anxiety = feeling nervous)Best Wellbeing012345678910 worst Possible Wellbeing(Wellbeing = how you feel overall)No _____012345678910 worst Possible _____Other Problem (For example constipation)Patient Name _____Completed by (Check one) Patient family Caregiver Health Care Professional Caregiver Caregiver-assistedBody Diagram on ReverseDate (yyyy-Mon-dd)Time (hh:mm)Please circle the number that best describes how you feel NOW:Side APlease mark on these pictures where it is that you hurt:Side B
