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
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
