ISUCRS AND ESCP AUDIT - Surgeon Registration Form

GLOBAL ISUCRS AND ESCP AUDIT ON OFFICE-BASED

AND SURGICAL TREATMENT OF HAEMORRHOIDS

SURGEON REGISTRATION FORM

1. Principle Investigate Name

2. Hospital Name

3. Hospital Address

4. Contact person E-mail address

5. Please describe your position

Clear choice

General surgeon

General surgeon with a strong interest in colorectal diseases

Colorectal surgeon

Proctologist only

Other

If OTHER above please specify

7. Do you use any grading system to classify hemorroids?

Clear choice

Yes

8. Do use any patient reported outcomes to measure the success of hemorroidal treatment?

Clear choice

Yes

If YES, which one?

Clear choice

PROM - Haemorroid severity score

PROM - Haemorroid Impact and Satisfaction Score (PROM-HISS)

Both

Hemorroidal disease and anl fissures upon quality of life (HEMO-FISS-QoL)

Others?

If OTHER above please specify

Verification