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| 1. What is your gender? |
| Female (93.2%) |
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| Male (6.8%) |
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| 2. What is your age? |
| Under 21 (4.2%) |
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| 21 - 30 (29.2%) |
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| 31 - 40 (28.5%) |
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| 41 - 50 (22.7%) |
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| 51 - 60 (11.7%) |
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| 61 - 70 (2.9%) |
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| 71 - 80 (0.8%) |
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| Over 80 (0.1%) |
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| 3. Have you been diagnosed with IC? |
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3b. If no, do you experience the symptoms of IC (pain, urinary frequency and urgency), but have never been officially diagnosed? |
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| 4. Do you feel that your IC negatively affects your ability to share sexual intimacy with your partner? |
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| 5. Do you experience increased IC pain and/or urinary urgency/frequency because of sexual activities? |
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| 6. If you experience increased pain with sexual activity, are you able to have intercourse? |
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| 7. Are you able to participate in any form of sexual activity with your partner? |
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| 8. Do the symptoms of IC decrease the frequency of your sexual activity? |
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| 9. Do you feel that IC has decreased your libido (desire for sex)? |
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| 10. If you are taking medications to treat your IC, do you feel that these medications have diminished your ability to become sexually aroused? |
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| 11. Do you abstain completely from sexual intimacy because of your IC symptoms? |
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| 12. Do you experience flares in your IC symptoms before and/or during and/or after sexual activities (please choose as many as applicable)? |
| Before sexual activites (13.7%) |
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| During sexual activites (33.1%) |
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| After sexual activites(53.2%) |
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| 13. Do you feel that your partner understands how IC affects you sexually? |
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| 14. Has your treating physician been willing to discuss with you the sexual problems that you may be encountering because of your IC? |
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| 15. Do you feel that your treating physician is comfortable discussing IC-related sexual issues with you? |
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| 16. Has your treating physician ever offered you advice and/or treatments (lidocaine gel, pain relievers, etc.) to help you with IC-related sexual concerns? |
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| 17. Have you ever been involved in a relationship that has ended because of IC-related sexual issues? |
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| 18. Have you ever decided not to begin an intimate relationship with a potential partner because of your IC? |
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