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Family or surname:
   
 
 
 
Given name or first name and middle initials:
   
 
 
 
Date of birth:
 
 
 
What is your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is wrong with you:
 
fever
 
burn
 
numbness
 
weight loss
 
hemorrhoids
 
pain
 
tumour
 
sprain
 
stomach ache
 
bloody stools
 
injury
 
lump
 
itching
 
swelling
 
other
 
 
 
Your problem (give a short description):
   
 
 
 
Duration of the problem (do not try to be too exact, just give some indication, that will be fine):
 
Seconds (up to 5 minutes or 300 seconds)
 
Minutes (up to 60 minutes)
 
Hours (1-12 hours)
 
Day (0.5 to 2 days)
 
Days (2 to 6 days)
 
Week
 
Longer
 
 
 
Longer duration of the problem:
 
Week
 
Months (over 3 months)
 
Months (over 6 months)
 
Years (over 1 year)
 
Years (over 5 years)
 
Other
 
 
 
 
Did you have the same problem before:
 
Yes
 
No