PUF QUESTIONNAIRE
PELVIC PAIN and URGENCY/FREQUENCY PATIENT SYMPTOM SCALE
To help your physician determine if you have interstitial cystitis (IC), also known as painful bladder syndrome (PBS),
please answer the following questions by providing the number score associated with the best possible answer.
PATIENT’S NAME:
TODAY’S DATE:
SCORE
0
1
2
3
4
1
How many times do you go to the
bathroom during the day?
3-6
7-10
11-14
15-19
20+
2A
How many times do you go to the
bathroom at night?
0
1
2
3
4
2B
If you get up at night to go to the
bathroom, does it bother you?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
3A
Do you now or have you ever had pain
or symptoms during or after sexual
intercourse?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
3B
Has pain or urgency ever made you
avoid sexual intercourse?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
Do you have pain associated with your
bladder or in your pelvis (vagina, labia,
lower abdomen, urethra, perineum,
testes, or scrotum)?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
MILD
MODERATE
SEVERE
4
5A
If you have pain, is it usually
5B
Does your pain bother you?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
6
Do you still have urgency after
going to the bathroom?
NEVER
OCCASIONALLY
USUALLY
ALWAYS
7A
If you have urgency, is it usually
MILD
MODERATE
SEVERE
7B
8
Does your urgency bother you?
OCCASIONALLY
USUALLY
ALWAYS
NEVER
SYMPTOM
SCORE
BOTHER
SCORE
Are you sexually active? YES / NO
*Developed by C. Lowell Parsons et al; PUF Questionnaire (Pelvic Pain, Urgency, and Frequency) © 2002.
SEE RESULTS ON NEXT PAGE
Visit www.defeatic.com for
more information on symptoms
and diagnosis for IC/PBS.
SYMPTOM SCORE
(1, 2A, 3A, 4, 5A, 6, 7A)
BOTHER SCORE
(2B, 3B, 5B, 7B)
TOTAL SCORE
(SYMPTOM SCORE + BOTHER SCORE)
HOW TO READ YOUR RESULTS
©2015 Imprimis Pharmaceuticals, Inc. All Rights reserved.
After adding your symptom score and your bother score,
use that score to read your results summary on the next page.
PUF QUESTIONNAIRE
PELVIC PAIN and URGENCY/FREQUENCY PATIENT SYMPTOM SCALE
Use your combined score from the previous page to read your results summary below.
SCORE OF 0-4
You have a risk of less than 2% chance of having a positive potassium sensitivity test (PST). A positive PST is known to
be associated with problems in the bladder epithelial that can be typically present in patients with interstitial cystitis (IC), also
known as painful bladder syndrome (PBS). It has been shown that approximately 80% of patients with IC/PBS have tested
positive when given the PST. It has been shown in a study that up to 1 in 4 may be at risk of having symptoms associated to IC. Visit
www.DefeatIC.com for more information on symptoms and diagnosis for IC/PBS.
SCORE OF 5-9
You have a risk of 55% chance of having a positive potassium sensitivity test (PST). A positive PST is known to be associated with
problems in the bladder epithelial that can be typically present in patients with interstitial cystitis (IC), also known as painful
bladder syndrome (PBS). It has been shown that approximately 80% of patients with IC/PBS have tested positive when given
the PST. If you are having symptoms continuously, you should consult your doctor as you may be at risk for IC. Visit
www.DefeatIC.com to find an IC specialist today.
SCORE OF 10-14
You have a risk of 74% chance of having a positive potassium sensitivity test (PST). A positive PST is known to be associated
with problems in the bladder epithelial that can be typically present in patients with interstitial cystitis (IC), also known as
painful bladder syndrome (PBS). It has been shown that approximately 80% of patients with IC/PBS have tested positive when
given the PST. You are at high risk and should consult your symptoms with your doctor. It is recommended you consult with an
IC specialist, as they can provide a timely and proper diagnosis. Visit www.DefeatIC.com to find an IC specialist today.
SCORE OF 15-19
You have a risk of 76% chance of having a positive potassium sensitivity test (PST). A positive PST is known to be associated
with problems in the bladder epithelial that can be typically present in patients with interstitial cystitis (IC), also known as
painful bladder syndrome (PBS). It has been shown that approximately 80% of patients with IC/PBS have tested positive
when given the PST. You are at high risk and should consult your symptoms with your doctor. It is recommended you consult
with an IC specialist, as they can provide a timely and proper diagnosis. Visit www.DefeatIC.com to find an IC specialist today.
SCORE OF 20 OR HIGHER
You have a risk of 91% chance of having a positive potassium sensitivity test (PST). A positive PST is known to be associated with
problems in the bladder epithelial that can be typically present in patients with interstitial cystitis (IC), also known as painful
bladder syndrome (PBS). It has been shown that approximately 80% of patients with IC/PBS have tested positive when given
the PST. You are at high risk and should consult your symptoms with your doctor. It is recommended you consult with an IC
specialist, as they can provide a timely and proper diagnosis. Visit www.DefeatIC.com to find an IC specialist today.
*Developed by C. Lowell Parsons et al; PUF Questionnaire (Pelvic Pain, Urgency, and Frequency) © 2002.
Reference:
Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom
questionnaire and intravesical potassium sensitivity. Urology 60(4): 573-578, 2002.
Defeat ICTM is a trade mark of Imprimis Pharmaceuticals, Inc. ©2015 Imprimis Pharmaceuticals, Inc. All Rights reserved.