Anal Fistula Assessment

Fill up the following details in order to register.

    Please provide the following information as accurately as possible

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


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


    Is it painful when pus collects at the site?

    Does it burst intermittently?


    Does the pain subside after it bursts open?

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


    Is there?
    Foul smellPusBloodStoolSticky Mucous

    Is there itching / purities at the site?

    Are you suffering from any inflammatory bowel diseases?

    ColitisUlcerative ColitisProctitisChrohns DiseaseOthers

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

    Attach Biopsy Report:

    Attach Colonoscopy Report:

    Are you under treatment for the same?

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

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

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

    Please provide details

    Bowel habits*


    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?

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

    Abdomen discomfort & pain?

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

    Have you lost weight recently?

    Do you have a present / previous history of tuberculosis?

    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)

    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 :


    Control of Passage of Flatus (air):


    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