Patient Information


Name *
 
Phone*
 
Email*
 
Age*
 
Gender *
 
Occupation *
 
DO YOU FEEL SOMETHING COMING OUT THROUGH ANUS DURING BOWEL MOVEMENT(DEFECATION)? *
 
DOES IT GO AUTOMATICALLY UPWARD OR MANUALLY? *
 
ANY FEELING OF PAIN?*
 
DO YOU FEEL PROLAPSE IS AROUND ANUS OR ONE SIDED ? *
 
DO YOU FEEL ANY DISCHARGE (WATERY,SPOTTED BLOOD OR ANY THICK DISCHARGE)? *
 
DO YOU FEEL ANY OTHER ABNORMALITY IN AREA OF ANAL VERGE? *
 
DO YOU FEEL ANY RELAXATION IN ANAL OPENING? *
 
HOW IS YOUR BOWEL MOVEMENT(NORMAL,CONSTIPATION OR ANY OTHER)? *
 
HOW LONG HAVE YOU BEEN SUFFERING FROM THIS PROBLEM? *
 
DO YOU KNOW ANY SPECIFIC REASON FOR ONSET OF THIS PROBLEM? *
 

All Rights Reserved 2013-2017 @ ProlapseRectum.com - Website Designed & Developed By ingeniousesolutions.com | Non Surgical Treatment of Rectal Prolapse