Please explain how RLS has impacted your social, emotional and physical well-being, how long you have taken opioids to manage your RLS and how opioids have improved your overall quality of life: (in approximately 150 words or less)

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* 1. Please explain how RLS has impacted your social, emotional and physical well-being, how long you have taken opioids to manage your RLS and how opioids have improved your overall quality of life: (in approximately 150 words or less)

Do you give the RLS Foundation permission to use your story in letters to legislators requesting their support for policies that allow continued access to opioids for RLS treatment?

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* 2. Do you give the RLS Foundation permission to use your story in letters to legislators requesting their support for policies that allow continued access to opioids for RLS treatment?

Name:

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* 3. Name:

Address

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* 4. Address

City:

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* 5. City:

State:

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* 6. State:

Zip Code

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* 7. Zip Code

Telephone number:

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* 8. Telephone number:

Email address:

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* 9. Email address:

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