Pediatric Restless Legs Syndrome Severity Scale Parent Questionnaire. Weekly Diary. Instructions:
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1 Pediatric Restless Legs Syndrome Severity Scale Parent Questionnaire Weekly Diary Questions 1-17 all ask about your child. Instructions: Answer thinking about your child during during the past 7 days. For the first 5 questions asking about nighttime, please think about the time from when your child went to bed until he/she got up in the morning. Please answer every question. 1. During the past 7 days, on average, from when your child lay down to try to sleep, approximately how long per night did it take your child to fall asleep? Less than 5 minutes 5-15 minutes minutes minutes 46 minutes 1 hour more than 1 hour 2. During the past 7 days, how much did your child s restless legs bother him/her when he/she was trying to get to sleep? Page 1 of 7
2 3. During the past 7 days, on average, how many times per night did your child wake up because of his/her restless legs? 0 times 1 time 2-3 times 4-5 times More than 5 times 4. During the past 7 days, on average, how many times per night did your child get up out of bed to try to get relief from his/her restless legs? 0 times 1 time 2-3 times 4-5 times More than 5 times 5. During the past 7 days, on average, how much sleep per night did your child lose due to restless legs? minutes 31 minutes - 1 hour 1-2 hours More than 2 hours Page 2 of 7
3 6. During the past 7 days, how often did your child mention having the restless legs feelings in his/her legs? 7. During the past 7 days, how irritable was your child? irritable irritable irritable Very irritable Extremely irritable 8. During the past 7 days, how grumpy was your child? grumpy grumpy grumpy Very grumpy Extremely grumpy 9. During the past 7 days, how much was your child upset by his/her restless legs? upset upset Very upset Extremely upset Page 3 of 7
4 10. During the past 7 days, how frustrated was your child by his/her restless legs? frustrated frustrated frustrated Very frustrated Extremely frustrated 11. During the past 7 days, how annoyed was your child by his/her restless legs? annoyed annoyed annoyed Very annoyed Extremely annoyed 12. During the past 7 days, how tired was your child? tired tired tired Very tired Extremely tired 13. During the past 7 days, how much did your child move (kick, stretch, wiggle) his/her legs to get rid of the restless legs feelings? Page 4 of 7
5 14. During the past 7 days, how difficult was it for your child to sit still? difficult difficult Very difficult Extremely difficult 15. During the past 7 days, how much did your child s restless legs make it difficult for him/her to stay focused? 16. During the past 7 days, how much did the restless legs feelings distract your child? Page 5 of 7
6 17. During the past 7 days, how much did your child s restless legs make it difficult for him/her to do homework? My child did not have homework Questions ask about the impact of your child s restless legs on your life (rather than your child s). Instructions: Answer thinking about the impact on your life during the past 7 days. Please answer every question. 18. During the past 7 days, how much did your child s restless legs disturb your sleep? 19. During the past 7 days, how frustrated have you felt about your child s restless legs? frustrated frustrated frustrated Very frustrated Extremely frustrated Page 6 of 7
7 20. During the past 7 days, how concerned have you been about your child s restless legs? concerned concerned concerned Very concerned Extremely concerned Page 7 of 7
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