* 1. Thank you for your interest in our research. To see if you are suitable to take part, please answer the following questions.

Please enter your full name and at least two ways we can contact you.

* 2. What is your date of birth?

* 3. Have you ever been diagnosed with haemorrhoids (piles) by your doctor?

* 4. If you use a topical treatment for piles, such as cream, spray or suppositories, please give details. Otherwise please write NONE.

* 5. Please tick Yes to each of the following bowel symptoms, if you have it. Otherwise, please tick No.

  Yes No
Bright red bleeding when you have a bowel movement. This may be just a tiny amount.
Feeling of fullness in the bowels even after a movement
Small lump outside the anus after a bowel movement
Itchiness, soreness or inflammation of the anus
Mucous discharge

* 6. Apart from symptoms of piles, are you in general good health?

* 7. Please tick Yes to any of the following symptoms which you may have. Otherwise, please tick No.

  Yes No
Dark red blood, or blood mixed in with the stools
Bleeding not associated with a bowel movement
Recent changes in bowel movements
Recent major weight loss

* 8. If you are currently taking herbal supplements or prescribed medications for any condition, please give details. Otherwise please write NONE.

* 9. Finally, please tick Yes or No to tell us if you are...

  Yes No
Allergic to sunflowers, oregano or Jerusalem artichoke?
Currently pregnant, planning a pregnancy, or breastfeeding?