.| .| Restless Legs Syndrome Rating Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | ||Scoring: 1-10 Mild RLS 11-20 Moderate RLS| 21-30 Severe RLS| 31-40 Very severe| | RLS|
RLS: <-RLS->| | 1. <*Answer_6664*>| 2. <*Answer_6665*>| 3. <*Answer_6666*>| 4. <*Answer_6667*>| 5. <*Answer_6668*>| 6. <*Answer_6669*>| 7. <*Answer_6670*>| 8. <*Answer_6671*>| 9. <*Answer_6672*>|
10. <*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 should be verified for
accuracy and used in conjunction with other diagnostic activities and procedures.| $~
|
