Survey Assessment Forms

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Survey Assessment Forms - Ayurvedic Multi Speciality Hospital in PCMC

Name
First Last
Email
Phone Number
Cutting like Pain during passing stools?
- Yes
- No
- Unbearable Pain / Sensitive to Touch
Bleeding during or after motions?
- Yes
- No
- Bleeding can be anytime while sitting/ Standing/ Travelling
History of Constipation ?
- No
- Habit to strain during passing stools
- Only first part is hard
- Liquid sticky stools are passed 2-3 or more times a day
- Passes normal stools but not satisfied
Pedicles felt at Anus?
- Only swelling felt during passing stools, feeling size of anus is reduced
- Pedicle felt at 12 O’clock position, or 6 O’clock position, or both.
- Pedicles felt at Anus, feeling of bulging at anus
- Feeling of something/pedicle coming out while passing stools, pedicles remain out/goes inside after motions.
Burning sensation?
- Yes
- No
- Feeling of burning/ erosions only while passing stools.
Suffering from any other diseases?
- Thyroid
- Diabetes
- Hypertension
- Any Other
Please Mention
Age
Weight
Suffering since
Only for females
Gone through delivery before --- Months
My periods are due within --- days

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Address
1st floor, Office No. C-02 Rachna house, opposite Westside mall, off good luck chowk, Shivajinagar, Pune, Maharashtra 411004
Phone numbers:
+91 98507 68422 | +91 90679 68420
Mail:
dr.nyanishadesai@gmail.com

Address
Shop No.13, Radha Krishna Complex, Tirupati Balaji Chowk, Indrayani Nagar, Bhosari, Pune, Maharashtra 411039
Phone numbers:
+91 98507 68422 | +91 90679 68420
Mail:
dr.nyanishadesai@gmail.com