Do you ever feel pain or discomfort inside when you sit or use the bathroom? *

No, it doesn’t bother me.

Yes, but it’s mild and comes and goes.

Yes, it’s frequent and really uncomfortable.

Do you feel a sense of pressure or fullness inside your rectum? *

No, not at all.

Sometimes, but I can manage it.

Yes, and it’s quite uncomfortable.

Have you noticed any bulging or swelling during bowel movements? *

No, nothing like that.

Yes, but it goes back on its own.

Yes, and I have to push it back in myself.

Do you feel like you have to strain during bowel movements? *

No, not really.

Sometimes, but it’s not every time.

Yes, almost every time I go

Have your symptoms been getting worse over time? *

No, they’ve stayed about the same.

A little, but I’m able to manage.

Yes, they’ve definitely gotten worse.

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First Name *

Last Name *

Phone *

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