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.

We care about your privacy. To see our Privacy Policy CLICK HERE.

[sws_divider_line]

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
[sws_divider_line]

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


[sws_divider_line]

Use the following scale to determine your total score.

Total Score Categories:

  • 0 = None
  • 1 = Mild
  • 2 = Moderate
  • 3 = Severe
  • 4 = Very Severe