Have the patient rate his/her symptoms for the following ten questions. The patient and 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.
(1) Overall, how would you rate the RLS discomfort in your legs or arms?
(2) Overall, how would you rate the need to move around because of your RLS symptoms?
(3) Overall, how much relief of your RLS arm or leg discomfort did you get from moving around?
□ Moderate relief
□ Either complete or almost complete relief
□ No RLS symptoms to be relieved
(4) How severe was your sleep disturbance due to your RLS symptoms?
(5) How severe was your tiredness or sleepiness during the day due to your RLS symptoms?
(6) How severe was your RLS as a whole?
(7) How often did you get RLS symptoms?
(8) When you had RLS symptoms, how severe were they on average?
□ Very severe (This means 8 hours or more per 24 hour per day)
□ Severe (This means 3 to 8 hours per 24 hour day)
□ Moderate (This means 1 to 3 hours per day 24 hour day)
□ Mild (This means less than 1 hour per 24 hour day)
(9) 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?
(10) How severe was your mood disturbance due to your RLS symptoms - for example angry, depressed, sad, anxious or irritable?
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