| RPT |
.| .| 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
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