Affix patient label within this box What matterrs the M
MOST to you TOD
DAY? (Screening for Distresss) Date:___
____________
__________
Screeningg completed as pa
art of New P
Patient Consult Navigation 
RT treatment Clinic Review
w Pain/Sympttom managemeent Informaation provided b
by Patient 
 Family  Assisted by family//healthcare team
m member Pleasse circle the n
number that best describe
es how you feeel NOW No pain 0 1 2 3 4 5
5 6 7 8 9 10 No tiredness (Tired
dness = lack of ene
ergy) 0 1 2 3 4 5
5 6 7 8 9 10 No drowsiness (Drowssiness = feeling sle
eepy) 0 1 2 3 4 5
5 6 7 8 9 10 W
Worst possible droowsiness No nausea 0 1 2 3 4 5
5 6 7 8 9 10 Worst possible nnausea No lack of appetite 0 1 2 3 4 5
5 6 7 8 9 10 Woorst possible lack oof appetite No shortness of breatth 0 1 2 3 4 5
5 6 7 8 9 10 Worsst possible shortneess of breath 0 1 2 3 4 5
5 6 7 8 9 10 W
Worst possible de pression 0 1 2 3 4 5
5 6 7 8 9 10 Worst possible aanxiety 0 1 2 3 4 5
5 6 7 8 9 10 W
Worst possible weell‐being No depression (Depression = feeling ssad) No anxiety (Anxieety = feeling nervo
ous) Best well‐being (Well‐‐being = how you feel overall) Worst possiblee pain Worst possible tirredness
Referral: Dietician Home Care Pharmacy Oxygen Therapy Pain Manageement Palliative Carre Social Work
Dentist Radiation On
ncology Medical Onco
ology Family Dr./NP py Physiotherap
Other:___________ ________________ Check all of the folllowing items that are CUR
RRENTLY conccerns for you
u TODAY Emotion
nal  Fears//Worries Sadnesss Frustraation/Anger Changes in appearance
e Intimaacy/Sexuality Physical Trou
uble with everydaay activities (ie. batthing, Concenttration/Memory dressing) Sleep Visio
on or hearing cha
anges Weight Num
mbness/Tingling Fever/C
Chills Chan
nges to skin/nailss Bleeding/Bruising Lymphedema/swellinng Cough Practicaal Senssitivity to cold Mouth SSores Work//School Difficultty swallowing Financces Gettin
ng to & from Special diet mational Inform
lness and/or trea
Heartbu
urn/indigestion appointm
ments Understanding my ill
atment Diarrhe
a Talking with the heallth care team Homee Care Constipation Makking treatment deecisions/Persona l Directive Accom
mmodation Bladderr problems Know
wing about availaable resources Drug C
Cost Dizzinesss Taking medications aas prescribed Health
h Insurance Headaches Quittting smoking Spiritual Meaning/Purp
pose of life Faith Social/Family Feeling a burdeen to others Worry about faamily/friends Feeling alone
Support with cchildren/partner
Fall Prevention
History of prevvious fall Sensory deficitts Impaired mobiility Generalized weakness Cognitive chan
nges Taking diureticcs, laxatives or na
arcotics No concern ideentified  CPC rreviewed with paatient Patient’s Priority: Pleasse mark patient’s top priority w
with an asterisk (*) from either EESAS or CPC listt or  Other Priiority Concern: ___________________ Responsee/Management off distress Provid
ded emotional su
upport Provided information//education Me
edication adjusteed Further asssessment/testin
ng ot completed due to  illness  patient declined  language barrrier  literacy  vision issues  uunable to reach 
other:______________________
______ Form no
STAFF Comments: Form not reviewed wiith patient: Reasson:__________
______________
_____________________________________________________________________
_____ SSignature (of Hea lth Care Professio
onal) Reviewed
d by (Name of Hea
alth Care Professional) ESAS‐R
R & Canadian Prob
blem Checklist Daate (MM‐DD‐YYYY
Y)
Revision December 2015 Screening for Distress Tool: We are concerned about your physical and emotional well‐being and our staff of oncologists, nurses, dietitians and social workers want to be able to work toward addressing any concerns you may have. On the back side of these instructions is the Screening for Distress Tool. You are being asked to complete it while waiting to see your oncologist. This tool has been developed by the Saskatchewan Cancer Agency and includes nationally used screening questions to better help our staff identify issues/concerns you may be having. There is a Patient and Family Supportive Resource Sheet in each examination room that shows the various types of action that can be taken. Please take time to have a look at it while waiting for the oncologist to come into the room. The first component is the Edmonton Symptom Assessment System, or ESAS. You are being asked to circle the number that best indicates how you are feeling at the present time, with 0 indicating the best possible feeling, and 10, the worst. The second component is the Canadian Problem Checklist. You are being asked to tick off each box that reflects issues or concerns that you have experienced within the last week, including today. We invite you to have a family member assist you in the completion of the form and if you need further instructions on how to complete the form, please ask one of our volunteers to help you. Please give the form to the nurse when she calls you for your appointment. As with any written documentation in the Cancer Center, your answers are confidential and will be used to provide the best care for you and your family.