Appointments
Welcome
About SleepDoctors
Our Team
John Swieca
Juan Mulder
Mariannick Le Guen
Ksenia Chamula
Caroline Kronborg
Toby Fothergill
Sleep Studies
Sleep Disorders
Sleep Apnoea
Restless Legs Syndrome
Insomnia
Narcolepsy
Parasomnias
Unrefreshing Sleep
Appointments
Welcome
About SleepDoctors
Our Team
John Swieca
Juan Mulder
Mariannick Le Guen
Ksenia Chamula
Caroline Kronborg
Toby Fothergill
Sleep Studies
Sleep Disorders
Sleep Apnoea
Restless Legs Syndrome
Insomnia
Narcolepsy
Parasomnias
Unrefreshing Sleep
RLS Rating Scale
Please rate your average Restless Legs Syndrome symptoms during the past week:
Today's Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
1. Overall, how would you rate the RLS discomfort in you 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 do you get from moving around?
*
(4) No Relief
(3) Slight Relief
(2) Moderate Relief
(1) Either complete or almost complete relief
(0) No RLS symptoms and therefore question does not apply
4. Overall, how severe is your sleep disturbance from your RLS symptoms?
*
(4) Very severe
(3) Severe
(2) Moderate
(1) Mild
(0) None
5. How severe is your tiredness or sleepiness from your RLS symptoms?
*
(4) Very severe
(3) Severe
(2) Moderate
(1) Mild
(0) None
6. Overall, how severe is your RLS as a whole?
*
(4) Very severe
(3) Severe
(2) Moderate
(1) Mild
(0) None
7. How often do you get RLS symptoms?
*
(4) Very severe (This means 6 to 7 days a week.)
(3) Severe (This means 4 to 5 days a week.)
(2) Moderate (This means 2 to 3 days a week.)
(1) Mild (This means 1 day a week or less.)
(0) None
8. When you have RLS symptoms, how severe are they on an average day?
*
(4) Very severe (This means 8 hours per 24 hour day or more.)
(3) Severe (This means 3 to 8 hours per 24 hour day.)
(2) Moderate (This means 1 to 3 hours per 24 hour day.)
(1) Mild (This means less than 1 hour per 24 hour day.)
(0) None
9. Overall, how severe is 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?
*
(4) Very severe
(3) Severe
(2) Moderate
(1) Mild
(0) None
10. How severe is your mood disturbance from your RLS symptoms – for example angry, depressed, sad, anxious, or irritable?
*
(4) Very severe
(3) Severe
(2) Moderate
(1) Mild
(0) None
Please add up all the numbers above to create a total score:
*
Thank you!
