IRLS Rating Scale
Remove the appropriate scales from the Patient Reported Outcomes Questionnaire Book and ask the patient to complete them in the following order: • RLS Quality of Life Questionnaire. • Medical Outcomes Study (MOS) Sleep Scale. • Profile Of Mood State (POMS) scale. • Hospital Anxiety and Depression Scale (HADS). • Patient Satisfaction Question.
Vital signs
Orthostatic vital signs
Orthostatic vital signs
integer
Time Vitals Taken
time
Blood pressure
integer
Pulse
integer
Please record any medical procedures performed since the last visit in the Medical Procedures section at the back of this book.
Please record any changes in concomitant medication since the last visit in the Concomitant Medication section at the back of this book.
Please record any adverse experiences observed or elicited by the following direct question to the patient: "Have you felt different in any way since the last visit?" in the Adverse Experience and/or SAE section at the back of this book.
Clinical Global Impressions
Laboratory evaluation
Date of blood sample
date
If ’Yes’, please record details in the Adverse Experiences and/or SAE Section at the back of this book and repeat at Follow-up.
boolean
If ’Yes’, please perform a pregnancy dipstick test and record result below.
boolean
If ’Positive’, please record details in the Adverse Experiences and/or SAE Section at the back of this book and repeat at Followup.
boolean
Dose and Meal Information
Last dose of study medication
text
Date and time of last meal
datetime