Restless Legs Syndrome Study.

Pre Consult information Questionaire

Thank you for your registration to take part in this study. Please fill out the form below prior to your initial consultation, and be as detailed as possible

Was there a definite onset or circumstance that caused this?
(eg time of day, during which activity and in what position, as a result from stress or after you do certain things)
Selected Value: 0
How bad is it?
• If so can you describe this sensation in as much detail as possible including what it feels like, where it is felt exactly and if there is direction to it (eg It is a shooting pain that travels from lower back via the back of the right leg to the toes).
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Tick any recent or past steps you have taken that apply
Briefly
Including frequency and dose.
If so please describe your level of experience
Selected Value: 0
E.g. "If only (this) would be achieved I would be happy"
(Siblings/ parents/ grandparents/ causes of death)
Briefly list
Please briefly list, incl. frequency and dose.
Including drinks, sugar in tea and treats like chocolate.