Interstitial Cystitis (IC) Self Evaluation Forms

Self-evaluation Instructions

We are seeking to give you better service and improve your results; we also need to report to the Interstitial Cystitis Association (ICA).

The following I.C. self-evaluation form will be a bridge between us.

Please follow the instructions below to score yourself.

1.The pain & burning : Please circle a number on the Evaluation Form based on your pain diary and the number in ( ) is your score of pain & burning.

2.Frequency: Please choose the worst one between day time and night time.

3.Please add all the numbers in ( ) you chose. The sum is your monthly score.

4.To evaluate yourself: use the total 10 scores:  * Over 7 Light Case * 4 - 7 Medium Case * Under 4 Severe Case

5.Results are evaluated as follows:

 * Good response: Increased 2 points or more in 1 - 3 months.

 *Moderate response: Increased less than 2 points in 3 months.

 *No response: Scores have not changed for over 3 months.

When you complete the form please send or fax it back to us.

You may either print out this page, or download a copy in

Microsoft Word (.doc)

or Acrobat Format (.pdf)

Please contact us to schedule an appointment at your earliest convenience.
(all visits by appointment only)