Score | |||||
---|---|---|---|---|---|
0 | 1 | 2 | 3 | 4 | |
Dysphagia Which of the following best describes your ability to swallow? | Normal | Can swallow most foods | Can swallow a soft diet | Can swallow fluids only | Unable to swallow saliva |
Odynophagia Which of the following best describes the severity of pain you experience when swallowing? | No pain | Mild pain | Moderate pain | Severe pain | – |
Regurgitation Which of the following best describes how frequently you experience acid reflux, heart burn and/or the sensation of burning in the esophagus? | Never | Infrequent | Frequent | Constant | – |
Chest-back pain Which of the following best describes your chest and/or back pain? | No pain | Pain relieved by non-narcotics | Pain not relieved by non-narcotics or requiring an opiate medication | – | – |
WHO Performance status Which of the following best describes your symptoms and activity level on a daily basis? | Fully active, able to carry on all pre-disease performance without restriction | Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature | Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours | Capable of only limited selfcare, confined to bed or chair > 50% of waking hours | Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair |
Overall well-being Which of the following best describes your quality of life now as compared to before you were treated for esophageal cancer? | “A lot better” | “A little better” | “The same” | “A little worse” | “A lot worse” |