Anal Fistula Assessment

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Please provide the following information as accurately as possible

Do you have an abscess / boil / opening / nodule in the perennial region?

YesNo

Is there redness / soreness / inflammation at the site? (In the perennial region)

YesNo

Is it painful when pus collects at the site?
YesNo

Does it burst intermittently?

YesNo

Does the pain subside after it bursts open?
YesNo

Is there any kind of discharge from the site? (If Yes then Specify)
YesNo

ContinuesIntermittent

Is there?
Foul smellPusBloodStoolSticky Mucous

Is there itching / purities at the site?
YesNo

Are you suffering from any inflammatory bowel diseases?
YesNo

ColitisUlcerative ColitisProctitisChrohns DiseaseOthers

Have you any biopsy report or Colonoscopy report for the confirmation of the diagnosis?
YesNo

Attach Biopsy Report:

Attach Colonoscopy Report:

Are you under treatment for the same?
YesNo

What type of treatment are you taking / have you taken?
SurgicalMedical

Are you suffering from? *
Recurrent dysenteryDiarrheaChronic anal fissureHemorrhoids/ PilesCancer (Malignancy)
Any other condition of the anus –rectum -colon
YesNo

What type of treatment do you take to rectify it? *

Please provide details

Bowel habits*

Frequency:

1 to 3 times3 to 6 timesMore then 6 times.

Consistency of Stool:

Dry and hardSoft but formedSemisolidWatery

Is the passage of stool associated with? *
BleedingMucous dischargePus dischargeMuco-purulant dischargeAbdominal pain

Do you experience a felling of not having evacuated your bowel completely even after passing stool?
YesNo

Are you suffering from Indigestion / Feeling of heaviness / blotted ness / in the abdomen?
YesNo

Abdomen discomfort & pain?
YesNo

Can you feel some mass (lymph glands) in the inguinal region?
YesNo

Have you lost weight recently?
YesNo

Do you have a present / previous history of tuberculosis?
YesNo

Have you carried out any investigation?
YesNo (If Yes then Select)

FistulogramMRIX-rayEndo-anal Ultra sound - sonography

Have you confirmed the diagnosis by getting your self examined by a Proctologist / Colo-rectal surgeon / General surgeon? (If Yes: If possible forward your surgeon remark / Notes / Opinion by attachment)
YesNo

Diagnosis Report:

Have you carried out other investigation?
YesNo (If Yes then Specify)

How many times:

Provide operation dates:

Your operative notes/ remarks:

If you have been operated previously specify the condition of your anal sphincters

Control of Passage of stool :

NormalPartialLost

Control of Passage of Flatus (air):

NormalPartialLost

Have you previously under gone any type of rectal surgery?
Yes(If Yes then Specify Details)No

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Ksharsutra Ligation       -      Fistulectomy Fistulotomy       -       Fibrine Glue - Managment for Anal Fistula       -       Core Technique For Anal Fistula       -       Vran Upakrama        -      Ksharvarti & Ksharpichu Technique       -       Hemorrhoidectomy (Open N Close Method)       -      IRC(Infra Red Coagulation) for Hemorrhoids       -       PPH(Stapler Hemorrhoidectomy) For Hemorrhoids       -       HAL (Hemorrhoidal Artery Ligation) Technique       -       Barran Band Ligation For Hemorrhoids       -      Kshar Karma(Chemical Cauterization) for Hemorrhoids       -       Sclaro Therapy       -       Jalouka - Leach Application Technique       -       Crayo Surgery       -       Laser Surgery       -       Radio Frequency Cauterization       -       Basti Treatment (Medicated Enima For IBS & U Colitis)       -       Chemical Cutrization Through Ayurvedic Drugs       -       Conservative Managment - Shaman Chikitsa For Anorectal Diseases       -      Surgery According to Ayurveda       -       Surgery According to Modern Science