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Movement Disorders Including essential tremor, dystonia and Restless Leg Syndrome (RLS). |
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09-27-2006, 09:36 AM | #1 | |||
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The following is a self assessment symptom questionnaire prepared by the International Restless Legs Syndrome Study Group.
The scores for each question are either 4 (which is the worst), 3, 2, 1 or 0 (which is the mildest). Adding up the total score will give you the severity of the Restless Legs Syndrome : Mild (if your total score 1-10) Moderate (if your total score is 11-20) Severe (if your total score is 21-30) Very severe (if your total is score 31-40) In the past week… 1. Overall, how would you rate the RLS discomfort in your legs or arms? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 2. Overall, how would you rate the need to move around because of your RLS symptoms? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 3. Overall, how much relief of your RLS arm or leg discomfort did you get from moving around? 4 - No relief 3 - Mild relief 2 - Moderate relief 1 - Either complete or almost complete relief 0 - No RLS symptoms to be relieved 4. How severe was your sleep disturbance due to your RLS symptoms? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 5. How severe was your tiredness or sleepiness during the day due to your RLS symptoms? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 6. How severe was your RLS as a whole? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 7. How often did you get RLS symptoms? 4 - From 6 to 7 days per week 3 - From 4 to 5 days per week 2 - From 2 to 3 days per week 1 - Only 1 day per week 0 - Not at all in the past week 8. When you had RLS symptoms, how severe were they on average ? 4 - Very severe (8 hours or more per 24 hour) 3 - Severe (3 to 8 hours per 24 hour) 2 - Moderate (1 to 3 hours per 24 hour) 1 - Mild (less than 1 hour per 24 hour) 0 - None 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. 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None 10. How severe was your mood disturbance due to your RLS symptoms - for example angry, depressed, sad, anxious or irritable? 4 - Very severe 3 - Severe 2 - Moderate 1 - Mild 0 - None Last edited by The Godfather; 09-27-2006 at 10:51 AM. |
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