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Cambridge-Hopkins Restless Legs Syndrome - NINDS Common ...

Cambridge-Hopkins Restless Legs Syndrome - NINDS Common ...

Cambridge-Hopkins Restless Legs Syndrome - NINDS Common

VERSION 7 Jan2008 copyright: Richard P Allen, PhD, FAASM; Brendan Burchell, PhD (RichardJHU@me.com) Cambridge-Hopkins Restless Legs Syndrome DIAGNOSITC QUESTIONNAIRE Answer the questions as completely as you can. Please circle the one best answer to each question thus: 1. Do you have, or have you had, recurrent uncomfortable feelings or sensations in your legs while you are sitting or lying down? 2. Do you, or have you had, a recurrent need or urge to move your legs while you were sitting or lying down? Page 1 of 3 • Yes • No • Yes • No If you answered YES to either question 1 or 2 continue Question 3. If you answered NO to BOTH stop here . The following is about these feelings 3. Would you describe these feelings and the feeling of an urge to move the leg as usually: 4. Are you more likely to have these feelings when you are resting (either sitting or lying down) or when you are physically active? 5. Do these feelings usually start when you are resting (either sitting or lying down)? 6. If you get up or move around when you have these feelings do these feelings get any better while you actually keep moving? 7. Do you sometimes get up or move around for no other reason than because you have these feelings in your legs? 8. Do these feelings ever become overwhelming to the point that you cannot resist moving? 9. When you are awake and having these feelings, how often do you find your legs move or jump on their own without you making them move? 10a. Which times of day are these feelings in your legs most likely to occur? (Please circle one or more than one) 10b. Which times of day are these feelings in your legs least likely to occur? (Please circle one or more than one) 11. Will simply changing leg position by itself once without continuing to move usually relieve these feelings? ● More painful than uncomfortable ● Uncomfortable, but not really painful ● Both painful and uncomfortable ● Resting ● Active ● Yes ● No Yes No Don’t know Yes No Not sure ● Yes ● No Never Sometimes Often Almost always Always Morning Mid-day Afternoon Evening Night About equal at all times Morning Mid-day Afternoon Evening Night About equal at all times • Usually relieves Does not usually relieve • Don’t know

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