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Free Consultation  (Fistula in Ano)
Name
Email
Mobile
Age
Sex Male Female
Address
Profession
Marital Status MarriedUnmarried
Single   Divorcee  
Education
Blood Pressure
Weight   Kilograms
Height   Feet    Inches
Are You Vegetarian Non-Vegetarian
You are Dependent on Alcohol  Smoking     
Drugs     Coffee/Tea 
Type of Discharge ?
( What type of material is coming from the external opening of fistula ?) 		Blood Pus
FaecesGas Urine
Type of Pain ? Pricking   Cutting
ThrobbingBurning
Onset of disease ? Acute   Gradual     
Duration of disease ? Less Than One Year   
More Than One Year   
Bowel Habit (Condition of stomach) Normal   Constipated     Mucous   
Mucous & Blood   History of Trauma  
Previous Surgery
(Have you ever been operated) ? 		Yes     No 
Condition of Skin Near Fistula in Ano ? Normal         Inflammed     
Indurated      Ext. Piles or Tag   
Tenderness
(pain around the external opening) 		Present     Abscent   
Main Complaint
Personal History
Laboratory Investigation Reports
(if any like blood sugar, BTCT )
Other information,might be helpful