Interstitial Cystitis/Painful Bladder Syndrome and Sexual Function
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1. Basic Information and History

 
This survey is designed to study the relationship between Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and sexual function. The survey is a peer reviewed; statistically valid, internationally accepted questionnaire entitled The Index of Female Sexual Function. You will first be asked some questions regarding background information followed by the survey. The questions in the survey are indeed intimate, your privacy is a priority and at no time will you be asked your name or email address.
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1. Age
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2. Height
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3. Current Weight
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4. Approximate Weight at age 21:
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5. Marital Status:
6. Economic Status/Family Income:
7. Education History:
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8. State of Residence
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9. Postal (Zip) Code
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10. Have you been diagnosed with IC/PBS by a physician?
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11. Have you been prescribed medications for IC/PBS by a physician?
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12. Do you take any "non-Prescription or Over the Counter" Medications for your IC/PBS?
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13. Have any of your relatives had a history of IC/PSB?
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