Gender*MaleFemaleTransgender

Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweOthers

Please provide the following information as accurately as possible

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

YesNo

[group duration]

[/group]

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

YesNo

[group redness]

[/group]

Is it painful when pus collects at the site?
YesNo

Does it burst intermittently?

YesNo

[group burst]

Does the pain subside after it bursts open?
YesNo

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

[/group]

[group burst_detail]

ContinuesIntermittent

Is there?
Foul smellPusBloodStoolSticky Mucous

[/group]

Is there itching / purities at the site?
YesNo

[group itching]

[/group]

Are you suffering from any inflammatory bowel diseases?
YesNo

[group bowel_detail]

ColitisUlcerative ColitisProctitisChrohns DiseaseOthers

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

[group biopsy]

Attach Biopsy Report:

Attach Colonoscopy Report:

[/group]

Are you under treatment for the same?
YesNo

[group same]

[/group]

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

[/group]

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

[group anus]

[/group]

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

[group discomfort]

[/group]

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

[group lymph]

[/group]

Have you lost weight recently?
YesNo

[group weight]

[/group]

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

[group tuberculosis]

[/group]

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

[group investigation]

FistulogramMRIX-rayEndo-anal Ultra sound - sonography

[/group]

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

[group Proctologist ]

Diagnosis Report:

[/group]

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

[group other-investigation]

How many times:

Provide operation dates:

Your operative notes/ remarks:

[/group]

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

[group surgery]

[/group]

[group condition]

[/group]