Hemorrhoid Assessment

1. Do you have a known diagnosis of hemorrhoids?

2. Do you experience bleeding after using the bathroom or see blood in your stool or toilet?

3. Do you have any itching, fullness, or pain in the rectal area?

4. Do you ever have unintentional stool leakage?

Thank you for completing the assessment.

Please provide us with your contact information, so we can give you a call back.
Your privacy is very important to us. We will not share your information outside of our practice.