Palliative Patient Symptom Assessment (ESAS-r)

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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
For example C1B 0X1 or 12345
For example 902-555-5555
For example 902-555-5555
Please enter the 8-digits from your PEI health card.
(If no Physician/Nurse Practitioner please write none)