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FAQ
Male Form (Consultation Form for Male Sex Diseases)
Fields marked with an asterisk (*) are required.
 
*Name of the Patient
*Age   (Yrs.)
Weight   (Kg)
Height   (e.g. 5 feet, 7 inches)
Profession
*Email Address
Complete Postal Address
City
State
Zip
*Country
1. Marital Status   Married    Unmarried
2. If married,  
  (a) Date of Marriage     (DD / MM / YYYY)
  (b) No. of Children   
  (c) Age of eldest child  
  (d) Age of youngest child  
  (e)  At present, are you living with your wife ?   
Yes No
*3. Describe your main problems for which you
    want to seek our advice.
4. How is your physique ?
Fat Slim
5. How is your appetite ?
Good Poor
6. Do you have constipation ?
Yes No
7. Type of food that you eat.
Veg. Non-Veg.
8. Do you consume tobacco in any form ?
Yes No
9. Are you addicted to any other intoxicant
    (e.g., liquor/wine etc.) ?
Yes No
10. Do you take excessive quantity of tea
      or coffee ?
Yes No
11. Do you suffer from sleeplessness ?
Yes No
12. Do you suffer from excessive urination ?
Yes No
13. Do you feel any irritation or burning
      sensation while passing urine ?
Yes No
14. How is the flow of urine ?
Smooth Restricted
15. Do you suffer from Involuntary Urination ?
Yes No
16. Do you suffer from Spermatorrhoea
      (i.e., involuntary flow of semen) ?
Yes No
17. Do you have Nocturnal Emissions during
      sleeping, more than 2-3 times a month ?
Yes No
18. Do you feel any pain or swelling in testicles ?
Yes No
19. Do you suffer, or have you ever suffered
      from any venereal disease (Syphilis /
      Gonorrhoea) ?
Yes No
20. Does any mucous (pus / fluid) pass out with
      urine ?
Yes No
21. 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
22. Is there any deformity in the male organ ?
Yes No
23. If yes, clarify.    Systolic / Diastolic
24. Do you suffer from High Blood Pressure ?
Yes No
25. If yes, mention your blood pressure.
26. Are you suffering from Diabetes ?
Yes No
27. If yes, mention Blood Sugar :
Fasting PP Random
28. Have you suffered from any disease earlier ?
Yes No
29. If yes, name it.
30. If you have recently undergone a medical
      check-up pertaining to blood, urine, stool,
      sputum, any x-ray, ultrasonography, etc.,
      please mention the related reports.
31. Any other problem that you might like to state
      
 
 
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