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Edmonton Symptom Assessment Scale (ESAS Modified)


Modified Edmonton Symptom Assessment Scale

1a. Please rate your pain now.

  1. No pain
  2. Mild pain
  3. Moderate pain
  4. Severe pain

1b. Please rate your pain over the past three days.

  1. No pain
  2. Mild pain
  3. Moderate pain
  4. Severe pain

1c. Is your pain control acceptable to you?

  1. Very acceptable
  2. Acceptable
  3. Not acceptable

2. How would you describe your activity level during your last three days?

  1. Very active
  2. Somewhat active
  3. Minimally active
  4. Not active

3. How would you describe the amount of nausea during the last three days?

  1. Not nauseated
  2. Mildly nauseated
  3. Moderately nauseated
  4. Very nauseated

4. How would you describe your level of constipation in the last three days?

  1. No constipation
  2. Mild constipation
  3. Moderate constipation
  4. Severe constipation

4a. When was your last bowel movement?

  1. Today
  2. Yesterday
  3. Two-three days ago
  4. More than four days ago

How would you describe your feelings of depression during the last three days?

  1. Not depressed
  2. Mildly depressed
  3. Moderately depressed
  4. Very depressed

How would you describe your feelings of anxiety during the last three days?

  1. Not anxious
  2. Mildly anxious
  3. Moderately anxious
  4. Very anxious

How would you describe your level of fatigue during the last three days?

  1. Not fatigued
  2. Mildly fatigued
  3. Moderately fatigued
  4. Very fatigued

How has your appetite been during the last three days?

  1. Very good appetite
  2. Moderate appetite
  3. Poor appetite
  4. No appetite

How would you describe your sensation of wellbeing during the last three days?

  1. 1. Very good sensation of wellbeing
  2. 2. Moderately good sensation of wellbeing
  3. 3. Not very good sensation of wellbeing
  4. 4. Poor sensation of wellbeing

How short of breath have you been during the last three days?

  1. No shortness of breath
  2. Mild shortness of breath
  3. Moderate shortness of breath
  4. Very short of breath

How has your physical discomfort been during the last three days?

  1. No physical discomfort
  2. Mild physical discomfort
  3. Moderate physical discomfort
  4. Severe physical discomfort

Visual Analogue Scale

Name:__________________________________________

Room #:  ____________________

Please cross the line at the point that best describes: (for coding)

No Pain ____________________________________Worst Possible Pain

Not Tired ___________________________________Worst Possible Tiredness

Not Nauseated________________________________Worst Possible Nausea

Not Depressed________________________________Worst Possible Depression

Not Anxious___________________________________Worst Possible Anxiety

Not Drowsy___________________________________Worst Possible Drowsiness

Best Appetite__________________________________Worst Possible Appetite

Best Feeling of Well-Being________________________Worst Possible Feeling of Well-Being

No Shortness of Breath___________________________Worst Possible Shortness of Breath

Other Problems______________________________________________________________

 

Assessed by:________________________________________________________________ 

 

 

 

Revised 1/28/2000


Additional Resources

Toolkit of Instruments to Measure Care at the End of Life
An authoritative bibliography of instruments to measure the quality of care and quality of life for dying patients and their families.



Other Resources By



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