RLS Feedback form

Selected Value: 0
0 being unnoticeable and 10 being Severe
(eg time of day, during which activity and in what position, as a result from stress or after you do certain things)
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
0 being unnoticeable and 10 being severe
Selected Value: 0
0 being no impact- 10 being severe
Selected Value: 0
0 being no impact and 10 being severe
Selected Value: 0
0 being no impact and 10 being severe
Selected Value: 0
0 being no impact and 10 being severe
Selected Value: 0
0 being is no restlessness and 10 severe restlessness
Selected Value: 0
O being unnoticeable and 10 being severe
E.g. New products, reduction or increase in doses or strength of medications.
Briefly list, including medications used.
Selected Value: 0
Selected Value: 0
0 being extremely unhappy and 10 being extremely happy.