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
Need to get up and move around
Uncomfortable sensation in my legs
Creepy, crawly tingling sensation in my legs
What time of day do your symptoms usually start?
Early morning
Midday
Mid-afternoon
Early evening
Night
How often do your symptoms occur?
| Twice a day or more About once a day 2-3 times a week Once a week |
Several times a month Once a month Less than once a month |
What types of activities are affected by your Restless Legs Syndrome?
Ability to sit comfortably in the evening
Long rides
Airplane travel
Ability to sit during meetings
Going to the movies
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.
Yes, they affect my ability to stay asleep.
No, does not affect my sleep.
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.