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International Restless Legs Syndrome (IRLS) (NM800088)

International Restless Legs Syndrome (IRLS) (NM800088) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


NM800089 (Rev. 11/01/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
INTERNATIONAL RESTLESS LEGS
SYNDROME STUDY GROUP RATING SCALE
(IRLS)







Have the patient rate his/her symptoms for the following ten questions. The patient and not the examiner should make the
ratings, but the examiner should be available to clarify any misunderstandings the patient may have about the questions.
The examiner should mark the patient’s answers on the form.

In the past week…

(1) Overall, how would you rate the RLS discomfort in your legs or arms?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

In the past week…

(2) Overall, how would you rate the need to move around because of your RLS symptoms?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

In the past week…

(3) Overa ll, how much relief of your RLS arm or leg discomfort did you get from moving around?
4
□ No relief
3
□ Mild relief
2
□ Moderate relief
1
□ Either complete or almost complete relief
0
□ No RLS symptoms to be relieved

In the past week…

(4) How severe was your sleep disturbance due to your RLS symptoms?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None


Patient Name

DOB:

MR #


NM800089 (Rev. 11/01/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
INTERNATIONAL RESTLESS LEGS
SYNDROME STUDY GROUP RATING SCALE
(IRLS)







In the past week…

(5) How severe was your tiredness or sleepiness during the day due to your RLS symptoms?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

In the past week…

(6) How severe was your RLS as a whole?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

In the past week…

(7) How often did you get RLS symptoms?
4
□ Very often (This means 6 to 7 days a week)
3
□ Often (This means 4 to 5 days a week)
2
□ Sometimes (This means 2 to 3 days a week)
1
□ Occasionally (This means 1 day a week)
0
□ Never


In the past week…

(8) When you had RLS symptoms, how severe were they on average?
4
□ Very severe (This means 8 hours or more per 24 hour day)
3
□ Severe (This means 3 to 8 hours per 24 hour day)
2
□ Moderate (This means less than 1 to 3 hours per 24 hour day)
1
□ Mild (This means less than 1 hour per 24 hour day)
0
□ None





Patient Name

DOB:

MR #


NM800089 (Rev. 11/01/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
INTERNATIONAL RESTLESS LEGS
SYNDROME STUDY GROUP RATING SCALE
(IRLS)







In the past week…

(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?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

In the past week…

(10) How severe was your mood disturbance due to your RLS symptoms – for example angry, depressed, sad, anxious
or irritable?
4
□ Very severe
3
□ Severe
2
□ Moderate
1
□ Mild
0
□ None

























© IRLS Study Group 2001