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) I. C. Self Evaluation Form Name:_______________________ Phone:_____________________ Order #:___________ How long have you been diagnosed Interstitial Cystitis:___________________________ Your physician’s name:______________________________ phone:________________ Are you on Narcotics for your pain? No _____ Yes _____ Do you have other health problems? No _____ Yes _____ (use separate paper to explain) Symptoms Before I.C. Tea 1st Month After 2nd Month After 3rd Month & Later Pain & Burning Grade: Score: 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 Frequency Day Time: Night Time:   (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. (0) Under 15 min (1) 15 – 30 min. (2) 30min.- 1 hr. (3) 1 - 2.5 hr. (4) Over 2.5 hr. Energy Level (0) Limited (1) Good (0) Limited (1) Good (0) Limited (1) Good (0) Limited (1) Good Anxiety or Depression (0) Yes (1) No (0) Yes (1) No (0) Yes (1) No (0) Yes (1) No Month Scores           Please contact us to schedule an appointment at your earliest convenience. (all visits by appointment only)