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Male Problems Form
Male Problems
Form
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? *
YES
NO
6. Do you consume tobacco in any form? *
YES
NO
7. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? *
YES
NO
8. Do you take excessive quantity of tea or coffee? *
YES
NO
9. Do you suffer from sleeplessness? *
YES
NO
10. Do you suffer from excessive urination? *
YES
NO
11. Do you feel any irritation or burning sensation while passing urine? *
YES
NO
12. Do you suffer from Spermatorrhoea (i.e., involuntary flow of semen)? *
YES
NO
13. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)? *
YES
NO
14. Does any mucous (pus / fluid) pass out with urine? *
YES
NO
15. Have you suffered from any disease earlier? *
YES
NO
16. Any other problem that you might like to state. *
YES
NO
17. Do you feel any pain or swelling in testicles? *
YES
NO
18. Do you face the following problems?
(a) Lack of erection *
-
YES
NO
(b) Lack of stiffness *
-
YES
NO
(c) Premature ejaculation *
-
YES
NO
(d) Lack of sex desire *
-
YES
NO
19. Is there any deformity in the male organ? *
YES
NO
(a) ------If yes, clar
-
Systolic
Diastolic
20. Do you suffer from High Blood Pressure? *
YES
NO
21. Are you suffering from Diabetes? *
YES
NO
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