• Image field 3

  • RESTLESS LEGS SYNDROME RATING SCALE

  • Ask the patient to rate his or her symptoms for the following 10 questions. The patient, not the examiner, should make the ratings, but the examiner should be available to clarify any misunderstandings the patient may have about the questions. The examiner should mark the patient’s answers on the form. Point values are in parentheses after each answer.

    Please rate your average symptoms during the preceding week

  • Overall, how would you rate the restless legs syndrome (RLS) discomfort in your legs or arms?*
  • Overall, how severe was your RLS as a whole?*
  • Overall, how would you rate the need to move around because of your RLS symptoms?*
  • How often did you have RLS symptoms?*
  • Overall, how much relief of your RLS arm or leg discomfort did you get from moving around?*
  • When you had RLS symptoms, how severe were they onan average day?*
  • Overall, how severe was your sleep disturbance because of your RLS symptoms?*
  • Overall, how severe was the impact of your RLS symptoms on your ability to carry out your daily affairs (for example carrying out a satisfactory family, home, social, school, or work life)?*
  • How severe was your tiredness or sleepiness because of your RLS symptoms?*
  • How severe was your mood disturbance because ofyour RLS symptoms (for example, angry, depressed, sad, anxious, or irritable)?*
  • Format: (000) 000-0000.
  • Should be Empty: