Hemorrhoid History Form

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 Hemorrhoid History Form 
 
 
Patient Name: ______________________________________   
Today’s Date: _____________________ 
1. What is the reason for today’s visit?  _________________________________________ 
2. Do you experience any of the following symptoms? 
Pain or burning with bowel movements? 
   
Is the pain constant?     Yes       No         Is the pain only with bowel movements?       Yes       No      
Fevers or chills with rectal pain? 
Blood on the tissue paper when wiping or in the toilet bowl after a bowel movement?    
Anal itching? 
 
 
 
Difficulty or changes in bowel movements (diarrhea or constipation)? 
Tissue protrusion around the anus? 
3. Have you been treated for any of the following rectal problems in the past? 
Anal fissure 
 
 
Anal fistula 
 
 
Rectal prolapse 
Hemorrhoids   
 
Perirectal Abscess 
 
Anal warts or condylomas 
4. Do you use any regular fiber supplements?             Yes             No                                         
5. Have you had a previous colonoscopy?            Yes 
 No 
When and where?___________________________________________________________________________ 
What were the findings?______________________________________________________________________ 
6.  What relieves your symptoms? _________________________________________________________________ 
 
 
 

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