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REQUIP, a Medication for Restless Legs Syndrome

 
REQUIP is the First FDA-Approved Treatment for the treatment of Moderate-to-Severe Primary Restless Legs Syndrome (RLS)
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Restless Legs Syndrome Symptom Checklist

As with any medical illness or condition, only your health care professional can provide a diagnosis of symptoms of Restless Legs Syndrome (RLS). The following checklist is designed to help you recognize the symptoms of RLS and discuss these symptoms with your doctor; it is not intended to serve as a substitute for a diagnosis of RLS by a health care professional. If you think you may have RLS, you should visit your health care professional.

Click the answers that apply to you. When finished, click the “Submit” button below to receive a printable version of RLS symptoms to discuss with your health care professional.

Do you sometimes have a compelling urge to move your legs, often accompanied by uncomfortable leg sensations?
Yes       No

Does moving your legs provide temporary relief?
Yes       No

Do your leg symptoms begin or get worse when you are sitting, lying down, or trying to rest?
Yes       No

Does the urge to move your legs get worse in the evening or night?
Yes       No


If you answered "Yes" to any of the questions above about symptoms of Restless Legs Syndrome, check the boxes below that apply to you.

The uncomfortable sensations in my legs feel like: (Check all that apply.)
Tugging and/or pulling
Burning/aching
Tingling
Creepy-crawly
Twitching
Other

I have trouble falling asleep because of my leg symptoms.

Others in my family have the same problems.

My symptoms occur:
While sitting for long periods, such as at a business meeting
      or movie
During long car rides
While traveling on an airplane
While trying to fall asleep
Other

My symptoms usually start:
In the early morning
At midday
In the midafternoon
In the early evening
At night

My symptoms occur:
Daily
4-5 times a week
2-3 times a week
Once a week
Several times a month
Once a month

Be sure to tell your health care professional if you are pregnant or plan to become pregnant; you are breast-feeding; you have daytime sleepiness from a condition other than RLS; you are taking any prescription or over-the-counter medicines; you start or stop smoking; or you drink alcoholic beverages.