Restelss legs Syndrome - Symptom questionnaire

The Godfather · 09-27-2006, 09:36 AM

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

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Restelss legs Syndrome - Symptom questionnaire

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