IC & Trauma History Survey

Childhood or Adult Trauma and It's Relationship to IC/BPS

One of the associations we have seen in some IC patients is a history of trauma, often the result of physical injury at any age in life, or a history of emotional trauma, bullying or abuse. Our goal with this survey is to try to identify correlations between types of trauma and the onset of IC/BPS and/or widespread pain.

Absolutely no identifying information will be collected other than your gender, age and the country that you live in. Your privacy is very important. Thank you for your help!

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* 1. Have you been diagnosed with IC/BPS?

Yes

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* 2. Have you suffered with any other pain conditions? Select all that apply.

Irritable Bowel Syndrome (IBS)

Vulvodynia

Fibromyalgia

Endometriosis

Migraines

Chronic Fatigue Syndrome / ME

Prostatitis

Chronic Low Back Pain

Tension Headaches

TMJ/TMDD Jaw Disorders

None

Other (please specify)

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* 3. Have you suffered from any sensitivities? Please check all that apply.

Sensitive Skin

Sensitivity to Smells and Odors

Sensitivity to Bright Lights

Sensitivity to Chemicals and/or Medications

none

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* 4. How old were you when you first experience ANY urinary symptoms or any painful conditions, such as IC?

Under 10

11-20

21-30

31-40

41-50

51-60

61 and older

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* 5. Were you an athlete BEFORE the onset of your urinary symptoms or chronic pain? Please select your sports, even if you were just a casual player.

No, I was not an athlete

I rode bicycles regularly

I rode motorcycles

Football

Soccer

Ice skating / Ice hockey

Racquet sports

Gymnastics

Cheer/Dance/Ballet

Horsebackriding

Running / Track & Field

Triathlon/Elite Sporting

Other (please specify)

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* 6. Did you sustain any injuries from any accidents (i.e. cars, bicycle, horses, etc.) BEFORE your symptoms began?

Yes

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* 7. Have you experienced any of these injuries BEFORE the onset of your symptoms? Check all that apply.

injuries to the tailbone/coccyx

injuries to the sacrum

injuries to the back / spine / compressed discs

injuries to the hips

injuries to the legs or knees

injuries to the ankles or feet

injuries to the neck

injuries to the jaw

injuries to the head

not that I can recall

Other (please specify)

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* 8. Have you had any surgeries to your pelvic area? Check all that apply

C-section

Prolapse repair

Hip replacement

Ovarian cyst

Ectopic pregnancy

Hysterectomy

Prostatectomy

None

Other (please specify)

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* 9. Did you experience emotional trauma during your childhood? Please check all that apply.

Emotional Abuse From A Parent or Family Member

Alcoholic Parent

Violence From A Parent or Sibling

Sexual Abuse / Rape From A Parent or Sibling

Bullying At Home

Bullying At School or In My Neighborhood

Violence In My Community (gangs, rapes, murders, etc.)

None

Other (please specify)

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* 10. Did you feel safe in your childhood home?

Very Safe. I grew up in a happy, healthy home.

Somewhat Safe. There were just a few moments where my home felt unsafe, perhaps from alcohol or drug consumption.

Unsafe. My family home had violence in it frequently, such as fighting between siblings

Very Unsafe. I lived in fear of a parent or sibling who physically or emotionally abused me regularly.

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* 11. Did you feel safe in your community? Neighborhood? Schools??

Yes - Very Safe

Yes - Somewhat safe. There were rare moments when violence occurred.

No - There were more frequent moments when I felt unsafe, perhaps once a month.

No - I lived in a community that struggled with violence on a daily basis

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* 12. Do you or have you struggled with anxiety and/or catastrophic thinking?

No, I don't live with anxiety

I have suffered with anxiety in the past but it is now well controlled

I continue to struggle with anxiety and it periodically limits my life,

My anxiety is moderately severe and I struggle to keep it controlled.

My anxiety is so severe that I rarely leave my home.

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* 13. Do you believe the trauma you experienced has had a lasting impact on your mental or physical health?

Yes

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* 14. Have you sought health care for your trauma?

Yes, I have worked with a therapist or taken classes to help with overcoming my trauma and anxiety.

IC & Trauma History Survey

Childhood or Adult Trauma and It's Relationship to IC/BPS

Question Title

* 1. Have you been diagnosed with IC/BPS?

Question Title

* 2. Have you suffered with any other pain conditions? Select all that apply.

Question Title

* 3. Have you suffered from any sensitivities? Please check all that apply.

Question Title

* 4. How old were you when you first experience ANY urinary symptoms or any painful conditions, such as IC?

Question Title

* 5. Were you an athlete BEFORE the onset of your urinary symptoms or chronic pain? Please select your sports, even if you were just a casual player.

Question Title

* 6. Did you sustain any injuries from any accidents (i.e. cars, bicycle, horses, etc.) BEFORE your symptoms began?

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* 7. Have you experienced any of these injuries BEFORE the onset of your symptoms? Check all that apply.

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* 8. Have you had any surgeries to your pelvic area? Check all that apply

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* 9. Did you experience emotional trauma during your childhood? Please check all that apply.

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* 10. Did you feel safe in your childhood home?

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* 11. Did you feel safe in your community? Neighborhood? Schools??

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* 12. Do you or have you struggled with anxiety and/or catastrophic thinking?

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* 13. Do you believe the trauma you experienced has had a lasting impact on your mental or physical health?

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* 14. Have you sought health care for your trauma?

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* 15. How has your trauma impacted your life?

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* 16. What advice would you give another patient who has struggled with trauma?

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* 17. How old are you?

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* 18. What country do you live in?

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* 19. What sex were you when your symptoms began?