Name

Date: mm/dd/yyyy

Do you suffer from Constipation? Do you suffer from Constipation? Yes No

Do you suffer from Diarrhea? Do you suffer from Diarrhea? Yes No

Do you have to strain or push hard when having a bowel movement? Do you have to strain or push hard when having a bowel movement? Yes No

Does any tissue ever come out of your rectum (prolapse) during a bowel movement? Does any tissue ever come out of your rectum (prolapse) during a bowel movement? Yes No

Do you often feel like you’re “still not done” after a bowel movement? Do you often feel like you’re “still not done” after a bowel movement? Yes No

On average, do you drink the equivalent of 6-8 glasses of water per day? On average, do you drink the equivalent of 6-8 glasses of water per day? Yes No

Are you taking any fiber supplements? Are you taking any fiber supplements? Yes No

If so, which?

Time spent on toilet during average bowel movement in minutes? Time spent on toilet during average bowel movement in minutes? 0-10 10-20 20-30 30+

Symptoms (in Rectal Area) Symptoms (in Rectal Area) Bleeding Itching Prolapse Pressure/Swelling Leaking/Soiling Pain Burning

Are you allergic to latex? Are you allergic to latex? Yes No

Are you pregnant? Are you pregnant? Yes No

Are you taking any blood thinners (Coumadin, Plavix, Pradaxa, Xarelto, Eliquis, etc.)? Are you taking any blood thinners (Coumadin, Plavix, Pradaxa, Xarelto, Eliquis, etc.)? Yes No

Have you ever been diagnosed with Crohn’s disease, proctitis, cirrhosis or anal/rectal cancer? Have you ever been diagnosed with Crohn’s disease, proctitis, cirrhosis or anal/rectal cancer? Yes No

Are you taking immunosuppressant medication or undergoing radiation treatments? Are you taking immunosuppressant medication or undergoing radiation treatments? Yes No

Have you ever had a colonoscopy? Have you ever had a colonoscopy? Yes No