Hemorrhoid Artery Embolization Survey Complete this survey to help us assess your hemorrhoid symptoms. The answers you give in the survey below can help ARA experts determine if you might be a candidate for hemorrhoid artery embolization (HAE), a leading-edge, nonsurgical way to treat the pain, bleeding, and discomfort of hemorrhoids. Please fill out and submit the survey and an ARA interventional coordinator will contact you to help set up a consult, if appropriate. "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Questions about your knee pain:Questions about your knee pain:NoYesDo you have pain from hemorrhoids on a regular basis?Do you frequently have itching or discomfort in the anal area?Do you experience bleeding when passing stool?Have you had to deal with soiling from the anus because of hemorrhoids?Are your hemorrhoids swollen or prolapsed (outside the anus)?Do your hemorrhoids interfere with your daily life?Are you avoiding sexual activity because of hemorrhoids?Do you feel like your hemorrhoids are affecting your general well-being?ScoreSubmit your scores to ARA Diagnostic ImagingConsent to Submit Survey*If you replied “yes” to any of the above questions, you may benefit from HAE. Please enter the information below to submit your survey to us and we will follow up with you about next steps. Yes, I consent to submit my survey. Name* First Last Age*Date of birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Have you had treatment for your hemorrhoids?* Yes No Which of the following treatments have you had?Stool softeners* Yes No Sitz baths* Yes No Non-prescription creams/ointments* Yes No Pain relievers* Yes No Prescription drugs or ointments * Yes No Procedures or surgeries* Yes No What type?*Other