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Record important information about your health Make the most out of your visit to the doctor by printing out this page, completing the questionnaire and bringing it with you. Your responses will help the doctor diagnose your symptoms and recommend the most appropriate treatment option. Describe how your symptoms typically feel. Irresistible urge to move What time of day do your symptoms usually start? Early morning How often do your symptoms occur?
What types of activities are affected by your Restless Legs Syndrome? Ability to sit comfortably in the evening Do your symptoms affect your ability to get to sleep or stay asleep? Check all that apply. Yes, they affect my ability to fall asleep. List any over-the-counter medicines, vitamins or herbal supplements, and prescription medicines you are currently taking. Do you drink beverages containing caffeine or alcohol on a daily basis? If yes, note the amount consumed. Do you smoke? If yes, describe type and amount.
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