105 (105)    MH REPORT (601.93)

.|   .|   Restless Legs Syndrome Rating Scale|   |   Date Given: <.Date_Given.>|   Clinician: <.Staff_Ordered_By.>|   Location: <.Location.>|   |   Veteran: <.Patient_Name_Last_First.>|   SSN: 
should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.|      $~
<.Patient_SSN.>|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|   Gender: <.Patient_Gender.>|   |   |   |    RLS Score: <-RLS->|  | |   Scoring:|      Mild (1 - 10)|      Moderate (11 - 20)|     
 Severe (21 - 30)|      Very severe (31 - 40)  | |   Questions and Answers|   |   1. Overall, how would you rate the RLS discomfort in your legs or arms?|       <*Answer_6664*>|   2. Overall, how 
would you rate the need to move around because of your RLS symptoms?|       <*Answer_6665*>|   3. Overall, how much relief of your RLS arm or leg discomfort did you get from moving around?|       
<*Answer_6666*>|   4. How severe was your sleep disturbance due to your RLS symptoms?|       <*Answer_6667*>|   5. How severe was your tiredness or sleepiness during the day due to your RLS 
symptoms?|       <*Answer_6668*>|   6. How severe was your RLS as a whole?|       <*Answer_6669*>|   7. How often did you get RLS symptoms?|       <*Answer_6670*>|   8. When you had RLS symptoms, how 
severe were they on average?|       <*Answer_6671*>|   9. Overall, how severe was the impact of your RLS symptoms on your ability to carry out your daily affairs, for example, carrying out a 
satisfactory family, home, social, school or work life?|       <*Answer_6672*>|   10. How severe was your mood disturbance due to your RLS symptoms - for example, angry, depressed, sad, anxious or 
irritable?|       <*Answer_6673*>|   |   |   Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.  Assessment results