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Restless Leg Syndrome Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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RLS & Pain Related Symptoms
1

Do you experience pain-related symptoms with Restless Leg Syndrome?

Please select the option that best describes your experience.
2

On a scale of 1 to 10, how badly does Restless Leg Syndrome affect your quality of life?

Please rate the impact of Restless Leg Syndrome on your quality of life.
3

How would you describe the pain associated with Restless Leg Syndrome?

Please provide a brief description of the pain experienced.
4

Have you sought medical treatment for Restless Leg Syndrome?

Please indicate whether you have received medical treatment for your Restless Leg Syndrome.
5

Rate the frequency of your Restless Leg Syndrome symptoms.

Please rate how often you experience Restless Leg Syndrome symptoms.
6

How does Restless Leg Syndrome impact your daily activities?

Please describe how Restless Leg Syndrome affects your daily routine.
7

Are you currently taking any medication for Restless Leg Syndrome?

Please indicate if you are using any medication to manage your Restless Leg Syndrome.
8

Rate the severity of your Restless Leg Syndrome symptoms.

Please rate how severe your Restless Leg Syndrome symptoms are.
9

How does Restless Leg Syndrome impact your sleep quality?

Please describe how Restless Leg Syndrome affects the quality of your sleep.
10

How long have you been experiencing Restless Leg Syndrome symptoms?

Please specify the duration of time you have been experiencing symptoms of Restless Leg Syndrome.
11

What are the main symptoms you experience?

Select one or more answers
12

Does your Doctor take your RLS seriously?

Select one answer
13

What currently gives you the biggest amount of relief during bad episodes?

movement, painkillers etc
14

Ferritin levels are crucial in RLS. do you/have you had low iron levels?

RLS sufferers need a ferritin level over 100 to reduce symptoms.
15

finally, do you feel supported enough? or do you think that more needs to be done for RLS sufferers?

e.g better access to medicines, more research, support groups
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