Palliative Patient Symptom Assessment (ESAS-r) | eServices Prince Edward Island

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Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact Peter Howatt, Manager, Provincial Palliative Care Centre, 902-368-4781.

Identification

Is this your first time completing this assessment?

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

First Name

Middle Initial

Last Name

Telephone Number

For example 902-555-5555

What is your age?

Assessment completed by

Regional location

Personal Health Number (PHN)

Please enter the 8-digits from your PEI health card.

Name of Family Physician/Nurse Practitioner

(If no Physician/Nurse Practitioner please write none)