Overall, how would you rate the need to move around because of your RLS symptoms?
Very severe
Severe
Moderate
Mild
None
Overall, how much relief of your RLS arm or leg discomfort do you get from moving around?
No relief
Slight relief
Moderate relief
Either complete or almost complete relief
No RLS symptoms and therefore question does not apply
Overall, how severe is your sleep disturbance from your RLS symptoms?
Very severe
Severe
Moderate
Mild
None
How severe is your tiredness or sleepiness from your RLS symptoms?
Very severe
Severe
Moderate
Mild
None
Overall, how severe is your RLS as a whole?
Very severe
Severe
Moderate
Mild
None
How often do you get RLS symptoms?
Very severe (This means 6 to 7 days a week.)
Severe (This means 4 to 5 days a week.)
Moderate (This means 2 to 3 days a week.)
Mild (This means 1 day a week or less.)
None
When you have RLS symptoms, how severe are they on an average day?
Very severe (This means 8 hours per 24 hour day or more.)
Severe (This means 3 to 8 hours per 24 hour day.)
Moderate (This means 1 to 3 hours per 24 hour day.)
Mild (This means less than 1 hour per 24 hour day.)
None
Overall daily affairs, how severe is the impact of your RLS symptoms on your ability to carry out your ,for example carrying out a satisfactory family, home, social, school, or work life?
Very severe
Severe
Moderate
Mild
None
How severe is your mood disturbance from your RLS symptoms–for example angry, depressed, sad,anxious, or irritable?
Very severe
Severe
Moderate
Mild
None