Self Test for Men


	1.		Understand your symptoms
	2.		Take and print the IC self-test
	3.		Schedule a specific doctor visit
	4.		Prepare for your visit
	5.		Track your symptoms

Which best describes you?

	female, age 18-29

	female, age 30-39

	female, age 40-49

	female, age 50 or older

	male, age 18-29

	male, age 30-39 male, age 30-39

	male, age 40-49

	male, age 50 or older

Self-Test for Men

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1.	How many times do you urinate during the waking hours?
	3-6 7-10 11-24 15-19 20+

2a.	How many times do you urinate at night?
	0 1 2 3 4

2b.	If you get up at night to urinate, to what extent does it usually bother you?
	None Mild Moderate Severe

3.	Are you currently sexually active?
	Yes No (Skip to 4b)

4a.	IF YOU ARE SEXUALLY ACTIVE, do you now or have you ever had pain or urgency to urinate during or after sexual intercourse?
	Never Occasionally Usually Always

4b.	Has your pain or urgency ever made you avoid sexual intercourse?
	Never Occasionally Usually Always

5.	Do you feel any of the following symptoms (in any combination): unexplained pain and pressure in your penis, testes, and/or scrotum, the area above the pubic bone, the lower abdomen, the lower back, or the groin area, or during ejaculation?
	Never Occasionally Usually Always

6.	Do you still have urgency shortly after urinating?
	Never Occasionally Usually Always

7a.	If you have pain is it usually:
	Mild Moderate Severe

7b.	How often does your pain bother you?
	Never Occasionally Usually Always

8a.	If you have urgency, is it usually:
	Mild Moderate Severe

8b.	How often does your urgency bother you?
	Never Occasionally Usually Always

	How do I do this?


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