The following Restless Legs Syndrome Symptom Checklist has 10 simple questions that may help you identify common symptoms of Restless Legs Syndrome (RLS).

As with any medical illness or condition, only your doctor or other qualified healthcare professional can provide a diagnosis of Restless Legs Syndrome. The following Symptom Checklist is intended to help you recognize symptoms and is not intended to serve as a substitute for a diagnosis of Restless Legs Syndrome by a qualified healthcare professional. If you think you may have Restless Legs Syndrome, you should visit your doctor or other qualified healthcare professional as soon as possible. When evaluating your symptoms of RLS, your doctor will want to make sure they are not secondary to some other underlying condition. Be sure to discuss your symptoms with your healthcare provider so that your healthcare provider can determine whether you suffer from RLS.

Check the statements that apply to you. When finished, click "Continue" below.

	I sometimes have a compelling urge to move my legs, often accompanied by uncomfortable leg sensations.
	Moving my legs provides temporary relief.
	My leg symptoms begin or get worse when I am sitting, lying down, or trying to rest.
	The urge to move my legs gets worse in the evening or night.

If you checked any of the statements above, please answer the questions below.

How would you describe the uncomfortable sensations in your legs? Check all that apply.

	Creepy-crawly
	Burning
	Tingling
	Itching
	Twitching
	Other

Do you have trouble falling asleep or staying asleep because of your leg symptoms?
Yes       No

Do others in your family have the same problems?
Yes       No

Does your sleep partner tell you that you kick, twitch, or move in your sleep?
Yes       No

Do you feel sleepy or find it hard to concentrate after a restless night due to your leg symptoms?
Yes       No

When do your symptoms occur?

	When sitting for long periods such as a business meeting or movie
	During long car rides
	While traveling on an airplane
	While trying to sleep
	Other

What time of day do your symptoms usually start?

	Early evening
	Night

How often do your symptoms occur?

	Once a day
	Twice a day
	Once a week
	2-3 times a week
	4-5 times a week
	Once a month
	Several times a month