Patient Registration Form

First Name*
Middle Name*
Last Name*
Date of Birth*
Sex*
Occupation
Address*
Country*
State*
District*
City*
Tel No. *
Mobile
Email Address
Brief clinical history
Bleeding per rectum Yes No
Pain in or around the anus Yes No
Can you feel a hard painful mass around the anus? Yes No
Do you find it to difficult to sit? Yes No
Protrusion*
Something ( Mass) being felt at anal opening (digitally) during or after defecation (bowel movement) Yes No
Bowel history*
Constipation Yes No
Hard stool Yes No
Persistent feeling of stool left in the anal canal even after bowel movement Yes No
Loose motion Yes No
Frequency
Mucus with stool? Yes No
Itching in or around anal canal Yes No
Discharge Yes No
Are you suffering from? *
Diabetes
Hypertension
Liver disorders
Dysentery
Other
Are you taking Aspirin?* Yes No
Are you taking any other oral medicines? * Yes No
Have you taken any previous treatment for piles? * Yes No
Security Question (What's the Result?) *
 
 
Wednesday, October 18th, 2017

Best way to get rid of
PILES , FISSURES , FISTULAE is through
DR. Krishan Verma's
Treatment without any
side effects

Contact Address

Dr. Krishan Verma's Piles Clinic
Near Bus Stand, Near Park
Ch. Dadri (Bhiwani), Haryana (India)
Phone : +91-99964-05464
+91-94161-26910
Email : info@pilesclinicdadri.com
  
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