ESAS Survey | Ankr - Patient Navigation & Triage

Order Number

Cancer can affect your body in many ways. This short questionnaire rates the intensity of 9 common symptoms that you may experience.

Your team will receive a copy of this survey automatically and will reach out to you with next steps.

Who are you? *

Patient Family caregiver Healthcare professional caregiver Caregiver-assisted

Pain *

0 = No pain, 10 = Worst possible pain

Tiredness *

0 = No tiredness, 10 = Worst possible tiredness

Drowsiness (feeling sleepy) *

0 = No drowsiness, 10 = Worst possible drowsiness

Nausea *

0 = No nausea, 10 = Worst possible nausea

Lack of appetite *

0 = No lack of appetite, 10 = Worst possible lack of appetite

Shortness of breath *

0 = No shortness of breath, 10 = Worst possible shortness of breath

Depression (feeling sad) *

0 = No depression, 10 = Worst possible depression

Anxiety (feeling nervous) *

0 = No anxiety, 10 = Worst possible anxiety

Wellbeing (how you feel overall) *

0 = No wellbeing, 10 = Worst possible wellbeing

Any other problem (for example, constipation) *

0 = No __________, 10 = Worst possible ________

Here's your total score today:

/ 100

What is your email address? *

We will send a copy of your submission to this email

For The Oncology Institute patients only.

Did you like this content?

Tell us how we can improve this post?