Male Problem Form

Male Problems Form

Name

Email

Age

Weight (KG)

Mobille Phone NO

City

Country

Profession

Marital Status

Describe your main problems for which you want to seek our advice.

For how long, are you suffering from these problems?

How is your physique?

How is your appetite?

Do you have constipation?

Yes No

Do you consume tobacco in any form?

Yes No

Are you addicted to any other intoxicant (e.g., liquor/wine etc.)?

Yes No

Do you take excessive quantity of tea or coffee?

Yes No

Do you suffer from sleeplessness?

Yes No

Do you suffer from excessive urination?

Yes No

Do you feel any irritation or burning sensation while passing urine?

Yes No

Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise?

Yes No

Are you a patient of High Blood Pressure?

Yes No

Do you suffer from Spermatorrhoea (i.e., involuntary flow of semen)? *

Yes No

Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)?

Yes No

Does any mucous (pus / fluid) pass out with urine?

Yes No

Have you suffered from any disease earlier?

Yes No

Any other problem that you might like to state

Yes No

Do you feel any pain or swelling in testicles?

Yes No

Do you face the following problems?

Yes No

Lack of erection

Yes No

Lack of stiffness

Yes No

Premature ejaculation

Yes No

Is there any deformity in the male organ?

Yes No

Lack of sex desire

Yes No

------If yes, clarify

Dystolic Systolic

Do you suffer from High Blood Pressure?

Yes No

Are you suffering from Diabetes?

Yes No

Upload your Medical Report

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