Interstitial Cystitis Questionnaire - womenspelvichealth.com

1 Never Occasionally Usually Always0 1 2 3 4 Symptom ScoreBother ScoreHow many times do you urinate dur-ing the waking hours?How many times do you get out of bed to urinate?If you get up at night to urinate, to what extent does it usually bother you?Are you currently sexually active?YesNoIf you are sexually active, do you now or have you ever had pain or urgency to urinate during or after sexual intercourse?Has pain or urgency ever made you avoid sexual intercourse?Do you have pain associated with your bladder or in your pelvis (vagina, lower abdomen, urethra, perineum)?

2 Do you still have urgency shortly after urinating?If you have pain, is it usually:How often does your pain bother you?If you have urgency, is it usually:How often does your urgency bother you?12345678 0 1 2 3 4+ 3-6 7-10 11-14 15-19 20+None Mild Moderate SevereNever Occasionally Usually AlwaysNever Occasionally Usually AlwaysNever Occasionally Usually AlwaysNever Occasionally Usually Always Mild Moderate SevereNever Occasionally Usually Always Mild Moderate

3 SevereSymptom ScoreBother ScoreTotal ScoreInterpretation:0-4 = Negative5-9 = 57% Interstitial Cystitis10-14 = 75% Interstitial Cystitis15-19 = 79% Interstitial Cystitis20+ = 93% Interstitial CystitisThomas Dolnicek, ,FACOGR obert Dodds, ,FACOGP elvic Pain and Urgency/Frequency Patient Symptom Scale (PUF Scale)Specializing in urinary incontinence, pelvic floor disorders, pelvic pain, and general gynecology30055 Northwestern Hwy., Suite 235, Farmington Hills, MI 48334 Phone (248) 737-4600, Fax (248) 538-5020 Interstitial Cystitis Questionnair