Restless Legs Syndrome Severity Scale (Version xxx)Authorisation codeCurrent ageCommentGender Male Female1. How would you rate the intensity of the unpleasant symptoms of restless legs syndrome in the legs or arms? very strong strong medium weak none2. How much do you feel the need to move due to restless legs syndrome? very strong strong medium weak none3. How much does the unpleasant feeling in your legs or arms decrease when you move? very strong strong medium weak none4. To what extent is your sleep disturbed by your restless legs syndrome? very strong strong medium weak none5. Do you experience severe fatigue or drowsiness as a result of your restless legs syndrome? very strong strong medium weak none6. What is your overall assessment of the severity of your restless legs syndrome? very strong strong medium weak none7. How often do you experience restless legs syndrome? 6-7 days/week 4-5 days/week 2-3 days/week less than 1 hour/day never8. On days when you have symptoms of restless legs syndrome, how long do these symptoms last on average? ≥ 8 hours/day 3-8 hours/day 1-3 hours/day less than 1 hour/day no symptoms9. How does your restless legs syndrome affect your ability to perform your duties? very strong strong medium weak none10. To what extent does your restless legs syndrome affect your mood (anger, moodiness, depressive, sadness, anxiety, sensitivity, etc.)? very strong strong medium weak noneQuestionaire completed
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