• Basic Information
  • BRIEF CLINICAL HISTORY
  • OTHER MEDICAL HISTORY
  • BOWEL HISTORY
  • ARE YOU SUFFERING FROM

Basic Information

Name

Age

Mobile No.

Email

Address

City

State

Country

Date Of Appointment

BRIEF CLINICAL HISTORY

BLEEDING PER RECTUM/ PUS FORMATION

PAIN IN OR AROUND THE ANUS

CAN YOU FEEL A HARD PAINFUL MASS AROUND THE ANUS?

DO YOU FIND IT DIFFICULT TO SIT?

PROTRUDING MASS BEING FELT AT THE ANAL OPENING DURING OR AFTER DEFECATION

OTHER MEDICAL HISTORY

ARE YOU TAKING ASPIRIN

ARE YOU TAKING ANY OTHER ORAL MEDICINE/LAXATIVE?

HAVE YOU UNDERGONE ANY PREVIOUS SURGERY FOR PILES?

DIETARY PATTERN

Addiction (IF ANY)

Allergy (IF ANY)

HOW LONG HAVE YOU BEEN SUFFERING FROM PILES?

BOWEL HISTORY

CONSTIPATION :

HARD STOOL

PERSISTENT FEELING OF STOOL LEFT IN THE ANAL CANAL AFTER BOWEL MOVEMENT

LOOSE MOTION

MUCUS WITH STOOL

ITCHING IN OR AROUND THE ANAL CANAL

BURNING SENSATION

DISCHARGE

ARE YOU SUFFERING FROM

DIABETES

HYPERTENSION

HYPOTENSION

LIVER DISORDERS

DYSENTERY

OTHERS

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