Gender*MaleFemaleTransgender
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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)
Is it painful when pus collects at the site? YesNo
Does it burst intermittently?
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):
Have you previously under gone any type of rectal surgery? Yes(If Yes then Specify Details)No
