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Pradnyya Ayurveda
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Piles Treament
Fissure Treatment
Fistula Treatment
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Home
Specialties
Piles Treament
Fissure Treatment
Fistula Treatment
Gastric Treatment
Blog
Our Video
About Us
Survey Assessment Forms
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Survey Assessment Forms
Survey Assessment Forms - Ayurvedic Multi Speciality Hospital in PCMC
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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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Ayurvedic Multi Speciality Hospital in PCMC- Pradnya Ayurveda
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