Hemorrhoid Diagnostic Evaluation
Please complete this form to help us assess your symptoms and provide the best care.
Full Name
*
First Name
Last Name
Age
*
Contact Email
*
example@example.com
How long have you been experiencing symptoms?
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Which symptoms are you currently experiencing? (Select all that apply)
*
Pain or discomfort
Bleeding during bowel movements
Itching or irritation
Swelling around the anus
Lump near the anus
Other
Please rate the severity of your symptoms.
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do you have a history of hemorrhoids or similar conditions?
*
Yes
No
Not sure
Do you have any of the following medical conditions? (Select all that apply)
Chronic constipation
Chronic diarrhea
Liver disease
Bleeding disorders
None of the above
Have you used any treatments for your symptoms?
Yes, over-the-counter medication
Yes, prescription medication
Yes, home remedies
No
Please describe your usual bowel habits.
Please Select
Regular (once daily)
Irregular
Less than 3 times per week
More than 3 times per day
Do you have any of the following risk factors? (Select all that apply)
Pregnancy
Obesity
Sedentary lifestyle
Heavy lifting
None of the above
If you would like to provide any additional information about your symptoms or health, please do so here.
Submit Evaluation
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