Interstitial Cystitis (IC) Symptom and Problem Questionnaire

If you think you may be experiencing symptoms of interstitial cystitis (IC), complete this Profiler (both sections) and bring a copy to your physician. The Profiler does not provide a diagnosis of the disorder, but the information it contains and the results of diagnostic procedures performed by your physician can help make the diagnosis of IC. If you already are being treated for IC, this Profiler can help monitor your progress.

Note: Reload this page each time new data is entered to assure accurate results.

IC Symptom Index
During the past month, how often...
1. Have you felt the strong need to urinate with little or no warning?
Not at all
 Less than 1 time in 5
 Less than half the time
 About half the time
 More than half the time
 Almost always
0

 1

 2

 3

 4

 5
2. Have you had to urinate less than 2 hours after you finished urinating?
Not at all
 Less than 1 time in 5
 Less than half the time
 About half the time
 More than half the time
 Almost always
0

 1

 2

 3

 4

 5
3. Did you typically get up at night to urinate?
None
 Once
 2 time
 3 times
 4 times
 5 times or more
0

 1

 2

 3

 4
 5
4. Have you experienced pain or burning in your bladder?
Not at all Once a few times Almost always Fairly Often Usually
0

 1

 2

 3

 4

 5

Section Score
IC Problem Index
During the past month, how much has each of the following been a problem for you:
1. Frequent urination during the day?
No Problem Very small problem Small problem Medium problem Big problem
0

 1

 2

 3

 4
2. Getting up at night to urinate?
No Problem Very small problem Small problem Medium problem Big problem
0

 1

 2

 3

 4

 ?
3. Need to urinate with little warning?
No Problem Very small problem Small problem Medium problem Big problem
0

 1

 2

3

 4

 ?
4. Burning, pain, discomfort, or pressure in your bladder?
No Problem Very small problem Small problem Medium problem Big problem
0

 1

 2

 3

 4

 ?

Section Score

Publication Review By: the Editorial Staff at HealthCommunities.com

Published: 02 Apr 2002

Last Modified: 26 Jul 2011

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