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Home
About
About David
Sleep Speaker
Clinic
Attend Appointment
About the Clinic
Telehealth Consultations
Sleep Studies
Questionnaires & forms
Registration form
Prescription requests
FAQs
About Sleep
SleepHub
Sleep Research
Contact
Restless Legs Syndrome Rating Scale (IRLS)
Full Name
*
In the past week…
Overall, how would you rate the RLS discomfort in your legs or arms?
*
Very severe
Severe
Moderate
Mild
None
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 from your RLS arm or leg discomfort did you get from moving around?
*
No relief
Mild relief
Moderate relief
Either complete or almost complete relief
No RLS symptoms to be relieved
How severe was your sleep disturbance due to your RLS symptoms?
*
Very severe
Severe
Moderate
Mild
None
How severe was your tiredness or sleepiness during the day due to your RLS symptoms?
*
Very severe
Severe
Moderate
Mild
None
How severe was your RLS on the whole?
*
Very severe
Severe
Moderate
Mild
None
How often did you get RLS symptoms?
*
Very often (This means 6-7 days per week)
Often (This means 4-5 days per week)
Sometimes (This means 2-3 days per week)
Occasionally (This means 1 day a week)
Never
When you had RLS symptoms, how severe were they on average?
*
Very severe (This means 8 hours or more per 24-hour day)
Severe (This means 3-8 hours per 24-hour day)
Moderate (This means 1-3 hours per 24-hour day)
Mild (This means less than 1 hour per 24-hour day)
None
Overall, how severe was the impact of your RLS symptoms on your ability to carry out your daily activities, for example having a satisfactory family, home, social, school or work life?
*
Very severe
Severe
Moderate
Mild
None
How severe was your mood disturbance due to your RLS symptoms - for example being angry, depressed, sad, anxious or irritable?
*
Very severe
Severe
Moderate
Mild
None
Results
Total Score
Maximum 40
Symptom severity
Maximum 24
Symptom impact
Maximum 12
Send a copy
Enter email address if you would like a copy of the completed questionnaire.
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