| 1. | Do you have, or have you sometimes experienced, recurrent, uncomfortable feelings or sensations in your legs while sitting or lying down? | Yes | No |
| 2. | Do you have, or have you sometimes experienced, a recurrent need or urge to move your legs while sitting or lying down? | Yes | No |
| 3. | During the last 12 months, have these uncomfortable feelings or sensations in your legs, or the need to move your legs while sitting or lying down, happened to you on average for one or more nights/days per week? | Yes | No |
| 4. | When present, do these uncomfortable feelings or this urge to move become worse when you are resting (either sitting or lying down), than when you are active or moving about? | Yes | No |
| 5. | Are these uncomfortable feelings, or this urge to move, worse in the evening or at night, compared with the morning? | Yes | No |