Anal Fissure Physical Exam Form
Please complete the following details relevant to the anal fissure physical examination.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Symptoms (select all that apply)
*
Pain during bowel movements
Bleeding
Itching
Swelling
Other
Symptom Duration (in weeks)
*
Describe pain during bowel movements
Is there rectal bleeding?
*
Yes
No
Any changes in bowel habits?
*
Yes
No
Previous treatments attempted
Known allergies
Clinician Exam Notes
Submit Exam Form
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