Akathisia Clinical Assessment Form
Use this form to document symptoms, severity, medication history, and clinician observations related to akathisia.
Patient and Assessment Context
Patient Name or Initials
*
Age
*
Sex / Gender Identity
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinician / Assessor Name
*
Assessment Setting / Location
Please Select
Outpatient clinic
Inpatient unit
Emergency department
Primary care
Telehealth
Other
Symptom History
Symptom Onset Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate Onset Timing
Duration
Symptom Pattern
*
Constant
Intermittent
Unsure
Body Areas / Restlessness Pattern
Legs
Arms
Trunk
Whole body
Pacing
Shifting weight
Unable to stay still
Other
Describe the Sensations or Movements
Severity and Functional Impact
Overall akathisia severity
*
1
2
3
4
5
Distress / inner restlessness
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Impact on sitting still, sleep, work, or daily activities
*
No impact
1
2
3
4
5
6
7
8
9
Extreme impact
10
1 is No impact, 10 is Extreme impact
Clinician-rated observations
*
Rows
Absent
Mild
Moderate
Severe
Pacing
1
2
3
4
Leg movements
5
6
7
8
Inability to remain seated
9
10
11
12
Urge to move
13
14
15
16
Time-of-day pattern
None noted
Morning
Afternoon
Evening
Night
All day
Worse after medication dose
Other
Medication and Trigger Review
Current medications
Recent medication changes
*
Yes
No
Details of recent medication changes
Suspected triggering medication or dose change
Use of antipsychotics or antiemetics
Antipsychotics
Antiemetics
Both
Neither
Other
Symptoms after stopping or changing a medication
Improved
Worsened
No change
Unknown
Details of symptom change after medication adjustment
Clinician Observation and Impression
Observed movements during the visit
Pacing
Rocking
Shifting weight
Leg crossing and uncrossing
Foot tapping
Fidgeting
Unable to sit still
Other
Presentation consistent with akathisia?
*
Yes
Possibly
No
Unclear
Differential or contributing factors considered
Severity classification or brief clinical impression
Submit Assessment
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