Interstitial_Cystitis

INTERSTITIAL CYSTITIS (IC) SYMPTOMS AND
PROBLEMS QUESTIONNAIRE:

Please printout questions and answer them and bring into the office.

Date:

Name:

Identifying IC

To help your physician determine if you have IC, please put a check mark
next to the most appropriate response to each of the questions shown
below. Then add up the numbers to the left of the check marks and write
the total below.

IC Symptom Index


During the past month:

Q1. How often have you felt the strong need to urinate with little or no
warning?

0. Not at all.
1. Less than 1 time in 5
2. Less than half the time
3. About half the time
4. More than half the time
5. Almost always

Q2. Have you had to urinate less than 2 hours after you finished urinating?

0. Not at all.
1. Less than 1 time in 5
2. Less than half the time
3. About half the time
4. More than half the time
5. Almost always

Q3. How often did you most typically get up at night to urinate?

0. None
1. Once
2. 2 times
3. 3 times
4. 4 times
5. 5 or more times

Q4. Have you experienced pain or burning in your bladder?

0. Not at all
2. A few times
3. Almost always
4. Fairly often
5. Usually

Add the numerical values of the checked entries; Total score =

--------------------------------------------------------------------------------

IC Problem Index

During the past month how much has each of the following been a problem
for you:

Q1. Frequent urination during the day?

0. No problem
I. Very small problem
2. Small problem
3. Medium problem
4. Big problem

Q2. Getting up at night to urinate?

0. No problem
I. Very small problem
2. Small problem
3. Medium problem
4. Big problem

Q3. Need to urinate with little warning?

0. No problem
I. Very small problem
2. Small problem
3. Medium problem
4. Big problem

Q4. Burning, pain, discomfort, or pressure in your bladder?

0. No problem
I. Very small problem
2. Small problem
3. Medium problem
4. Big problem

Add the numerical values of the checked entries; Total Score =

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