Shreyas Hospital & Ano-Rectal Research Centre

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(*)-Compulsory Fields

Contact Details

• First Name*

• Middle Name*

• Last Name*

• Date of Birth*

• Sex*

• Occupation

• Address*

• Country*

• State*

• District*

• City*

• Tel No. *


Area Code	Telephone

• Mobile

• Email Address

Brief clinical history

• Bleeding per rectum Yes No

	after defecation ( Bowel movement)
	during and after defeacation
	during defeacation
	other
Since (week)

• Pain in or around the anus Yes No

	after defecation ( Bowel movement)
	during and after defeacation
	during defeacation
	constant
Since (week)

• Can you feel a hard painful mass around the anus?

Yes Since (week)

• Do you find it to difficult to sit?

Yes Since (week)

• Protrusion*

Something ( Mass) being felt at anal opening ( digitally) during or after defecation ( bowel movement) Yes No

dose the mass subside or goes inside after defeacation ?
	Spontaneously ( On its own)
	Manually ( By pushing in side the anal canal with your finger)
	Stays out side
Since (week)

• Bowel history*

• Are you suffering from? *

• Are you taking Aspirin?* Yes No

• Are you taking any other oral medicines?* Yes No

Please Mention the medicine name

• Have you taken any previous treatment for piles?* Yes No

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