Patient Information

Name *

Phone Number *

Email *

Age *

Gender *

Occupation *

City *

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? *

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