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