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THE INTERNATIONAL RESTLESS LIMB SYNDROME (IRLS) RATING SCALE

Please complete the form below and click “Submit” to send it to us. We will be in touch with you shortly. If you would prefer to download the form in PDF format and send it to us, please CLICK HERE to do so. Thank you.

Please Answer All Questions

Where a question is marked with * the following is true:
  • 0-1 days/week = Mild
  • 2-3 days/week = Moderate
  • 4-5 days/week = Severe
  • 6-7 days/week = Very Severe
Where a question is marked with ** the following is true:
  • < 1 hrs/day = Mild
  • 1-3 hrs/day = Moderate
  • 3-8 hrs/day = Severe
  • > 8 hrs/day = Very Severe

Use the information at the bottom of the form to determine your score.

General information
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Please rate your symptoms of RLS over the past 1-2 weeks based upon the following questions:
  1. Overall, how would you rate the RLS discomfort in your legs or arms?
  3. Overall, how would you rate the need to move around because of your RLS symptoms?
  5. Overall, how much relief of your RLS arm or leg discomfort do you get from moving around?
  7. Overall, how sever is your sleep disturbance from your RLS symptoms?
  9. How severe is your tiredness or sleepiness from your RLS symptoms?
  11. Overall, how severe is your RLS as a whole?
  13. How often do you get RLS symptoms? *
  15. When you have RLS symptoms, how severe are they on an average day? **
  17. When you have RLS symptoms, how severe are they on an average day?
  19. Overall, how severe is 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?
  21. How severe is your mood disturbance from your RLS symptoms, for example, angry, depressed, sad, anxious or irritable?
Use the scale below to determine your score.
 

Use the following scale to determine your total score.

Total Score Categories:
  • 0 = None
  • 1 = Mild
  • 2 = Moderate
  • 3 = Severe
  • 4 = Very Severe