Your Name *
Age *
Sex *
Weight (Kg) *
Mobile Phone No. *
Email *
City *
Country *
Profession *
Marital Status *
1. Describe your main problems for which you want to seek our advice. *
2. For how long, are you suffering from these problems? *
3. How is your physique? *
4. How is your appetite? *
5. Do you have constipation? * YESNO
6. Do you consume tobacco in any form? * YESNO
7. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? * YESNO
8. Do you take excessive quantity of tea or coffee? * YESNO
9. Do you suffer from sleeplessness? * YESNO
10. Do you suffer from excessive urination? * YESNO
11. Do you feel any irritation or burning sensation while passing urine? * YESNO
12. Do you suffer from Spermatorrhoea (i.e., involuntary flow of semen)? * YESNO
13. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)? * YESNO
14. Does any mucous (pus / fluid) pass out with urine? * YESNO
15. Have you suffered from any disease earlier? * YESNO
16. Any other problem that you might like to state. * YESNO
17. Do you feel any pain or swelling in testicles? * YESNO
18. Do you face the following problems? (a) Lack of erection * - YESNO (b) Lack of stiffness * - YESNO (c) Premature ejaculation * - YESNO (d) Lack of sex desire * - YESNO
19. Is there any deformity in the male organ? * YESNO
(a) ------If yes, clar - SystolicDiastolic
20. Do you suffer from High Blood Pressure? * YESNO
21. Are you suffering from Diabetes? * YESNO
Δ