* 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)

* 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?

* 3. Name:

* 4. Address

* 5. City:

* 6. State:

* 7. Zip Code

* 8. Telephone number:

* 9. Email address:

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