Survey

[Guest guest]

Group: a preliminary survey any feed back with changes, omissions

additions will be appreciated

Please use my E-mail address with comments do not add to or forward this

document or things might get

messy Thank you so very much for your cooperation

one more survey will be sent for final comments

Rodney 65 NEPA

1 Name

2 Age

3 Age at first symptoms of RLS

4 Age when diagnosed with RLS

5 Who diagnosed RLS

6 How many doctors did you see before you were diagnosed with RLS

7 based on a scale of 1 (least) to 10 (best) how well does your doctor

deal with you

8 Were your first treatments effective

9 Approximately how many medications have you tried

10 Did any work well

11 Is it still working

12 Are you still on this medication

13 What are you taking now

14 What worked best

15 Based on a scale of 1 (least) to 10 (best) how well does this work

for you

16 Do you use non prescription treatment

17 Does this work for you

18 Based on a scale of 1 (least) to 10 (best) how well does this work

for you

19 What are you taking

20 Have you tried a combination of medications

21 Does anyone else in your immediate family have RLS

22 What are their relation to you

23 What parts of your body are bothered most

24 Did you have any trauma before your RLS: i.e. operation, accident

25 Do you have pain with your RLS

26 Does your medication relieve your pain

27 (Female) Did you have RLS during pregnancy

28 (Female) Did it stay

30 Have you found an exercise that helps

29 How long does it help

30 Is there any thing that you have used that is still working

31 How much faith do you put into what other people are taking

32 Do you follow your doctors orders faithfully

33 Do you experiment with medication

34 Are you depressed

35 How often

36 Would you use a experimental drug

37 would you use a specialized diet

38 Can you see your self living with this the rest of your life

39 Would you support research for RLS

40 Describe your quality of life