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Questionnaire: Proctology (English)
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* Indicates required question
Full
Name
*
Your answer
Phone
Number
*
Your answer
MRN
*
Your answer
Do you suffer from constipation?
*
Yes
No
Is there blood during the exit?
*
Yes
No
Do you have pain while going out?
*
Yes
No
If you have pain during discharge, does this continue after discharge?
*
Yes
No
If you have pain in the anal area, is it only related to going out?
*
Yes
No
Do you have swelling in the anal area?
*
Yes
No
Do you have itching in the anal area?
*
Yes
No
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