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? *
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