Dose the patient being treated have any of the following conditions?

• Under 12 years old.

• Severe pain.

• Bleeding or seeping.

• Prolapse.

• Severe inflammation, swelling, or discomfort.

• Health conditions of the stomach or intestines.

• Have been diagnosed with a condition of the anus or rectum that is not hemorrhoids by a physician.

• Family history of colon cancer.

• Black tarry stools.

• Have hemorrhoids that have not improved after seven days of treatment.


Yes

No



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