RestlessLegs.com: My Symptom Checklist

RestlessLegs.com – find information on Restless Legs Syndrome (RLS)

About Restless Legs

Do I Have
Restless Legs Syndrome?

Living with
Restless Legs Syndrome

Sleep Disorders

Restless Legs Syndrome
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For Healthcare
Professionals

As with any medical condition, only your doctor or other qualified healthcare professional can provide a diagnosis of Restless Legs Syndrome (RLS). The following Symptom Checklist is intended to help you recognize symptoms and discuss your symptoms with your doctor; it is not intended to serve as a substitute for a diagnosis of Restless Legs Syndrome by a qualified healthcare professional. If you think you may have Restless Legs Syndrome, you should visit your doctor or other qualified healthcare professional as soon as possible.

Here are your results from the Symptom Checklist. Show your doctor these results, and ask him or her if you may have Restless Legs Syndrome.

Now that you have filled out this Symptom Checklist, talk to your healthcare professional to discuss your symptoms, as only he or she can diagnose Restless Legs Syndrome. We recommend that you take a printout of this page when you visit your healthcare professional. To print the page, go to your browser's File menu and select Print.

Restless Legs Syndrome can affect your sleep. However, it is not a primary sleep disorder like insomnia. So if you think you might have RLS, discuss your leg discomfort and compelling urge to move your legs before discussing any loss of sleep with your healthcare provider. This way, your doctor may diagnose and help manage your specific condition.

	I sometimes have a compelling urge to move my legs, often accompanied by uncomfortable leg sensations.
	Moving my legs provides temporary relief.
	My leg symptoms begin or get worse when I am sitting, lying down, or trying to rest.
	The urge to move my legs gets worse in the evening or night.

These uncomfortable sensations feel like:

	Creepy-crawly
	Burning
	Tingling
	Itching
	Twitching
	Other

I have trouble falling asleep or staying asleep because of my leg symptoms.
Yes No

Other people in my family have the same problem.
Yes No

My sleep partner tells me that I kick, twitch, or move in my sleep.
Yes No

I feel sleepy or find it hard to concentrate after a really restless night due to my leg symptoms.
Yes No

These activities are affected by my symptoms:

	When sitting for long periods such as a business meeting or movie
	During long car rides
	While traveling on an airplane
	While trying to sleep
	Other

I experience these symptoms:

	Early evening
	Night

My symptoms occur:

	Once a day
	Twice a day
	Once a week
	2-3 times a week
	4-5 times a week
	Once a month
	Several times a month