Restless Legs Syndrome Study Intake Form
Participant Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Contact Number
Email Address
Medical History
Have you been diagnosed with Restless Legs Syndrome?
Yes
No
At what age did your RLS symptoms begin?
How often do you experience RLS symptoms?
Daily
Weekly
Monthly
Rarely
Please describe your symptoms
Current medications (if any)
Other medical conditions
Family History
Does anyone in your family have Restless Legs Syndrome?
Yes
No
Unsure
Relationship (if yes)
Lifestyle Information
Caffeine consumption (describe)
Tobacco use
Never
Former
Current
Alcohol use
Never
Occasional
Regular
Physical activity (type and frequency)
Additional Comments