"*" indicates required fields 1General Health2Digestive Health3Personal Details gclid_fieldLet’s get started with a few questions about your general health.Are you pregnant?* Yes No Other than aspirin, are you taking any blood-thinning medications (anticoagulants) such as Coumadin® (warfarin), Eliquis® (apixaban), XARELTO® (rivaroxaban), Pradaxa® (dabigatran) or antiplatelets like Plavix® (clopidogrel), Effient® (prasugrel)?*Other than aspirin, are you taking any blood-thinning medications (anticoagulants) such as Coumadin® (warfarin), Eliquis® (apixaban), XARELTO® (rivaroxaban), Pradaxa® (dabigatran), or antiplatelets like Plavix® (clopidogrel), Effient® (prasugrel)? * Yes No Are you currently experiencing changes in bowel habits (dark or thinning stools), anemia, or unintentional weight loss?* Yes No Do you have symptoms of hemorrhoids such as anal bleeding with bowel movements, anal itching, discharge, prolapse of tissue from the anus, or discomfort in the anus?* Yes No Have you previously been diagnosed by a medical professional with internal hemorrhoids?* Yes No Have you previously tried conservative measures for the treatment of hemorrhoids such as over-the-counter or prescription creams, medicated wipes, sitz baths, increased dietary fiber intake, or fiber supplements?* Yes No Are you allergic to latex?* Yes No Tell us about your digestive health.Have you ever had a colonoscopy?* Yes No This field is hidden when viewing the form45 and ColonoscopyHave you been diagnosed with an inflammatory bowel disease (Crohn's disease or ulcerative colitis)?* Yes No Have you ever been diagnosed and treated for a perirectal abscess?* Yes No Have you ever been diagnosed with an immunodeficiency or currently taking immunosuppressive medications such as chemotherapy, biologics, or immunomodulators?* Yes No Have you ever been treated with radiation to your pelvis (prostate, cervical, or endometrial cancer)?* Yes No Have you ever been diagnosed with cirrhosis or liver damage?* Yes No Comments Tell us about yourself.First Name*Last Name*Birthday*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* ZIP Code Phone*Email* The answers provided will be used to determine your plan of care and will become part of your permanent medical record. If you are completing the questionnaire on behalf of the patient, verify the accuracy of each answer before submitting.StatusThis field is hidden when viewing the formEligibleThis field is hidden when viewing the formIneligible Δ