PATIENT FORM
Patient's Name:
E-mail:
Address:
State:
Country:
Zip code / Pin code:

Age:

Weight:

Height:

Occuption:

Sex:

Are you married?:

Yes:

No:

If so, how long

Children:

Do you feel passing of semen?

Before Urination

After Urination

After Stool

Does the discharge of semen occurs during sleep?	Yes		No
Do you feel your penis is bent or loose towards the leftside?	Yes		No
Do you feel weakness after the intercourse?	Yes		No
Are you suffering from premature ejaculation?	Yes		No
Do you get perfect erection before intercourse?	Yes		No
What is your duration of intercourse?

Do you have the habit of masturbation?

Yes

No

If so , since how long?

Are you

Vegetarian

Non-Vegetarian

Which type of food do you like?

Do you have Gastric Problem?		Yes		No
Do you have constipation?		Yes		No
What do you feel whenever you see a girl? (If you are not married) write in detail?

Have you suffer from

Syphillis

Gonorrhea

What is the length of your organ before erection

and after erection

How many times night discharge occurs in a week?

Do you read vulgar & obscene literature?

Yes

No

Does your underwear get wet when you see nude photographs?

Yes

No

Are you suffering from blood pressure?

Yes

No

If so, whether it is

Low BP

High BP

Do you suffer from heart problems?		Yes		No
Do you sleep well?		Yes		No

How many times you urinate at night?

Do you play Homosex (Man to Man)?		Yes		No
Do you exercise daily?		Yes		No

Do you feel pain after urinating?		Yes		No
Are you sufferingfrom diabetes?		Yes		No

Are you suffering from Appendicitics?

Yes

No

If so, when operation/treatment was held?

Have you ever met with fatal road accidents? If so, please furnish the full  details & complete test reports?

Do you take your food timely?		Yes		No
Do you take hot milk at bed time?		Yes		No

Is your wife older than you?

Yes

No

If so how many years?

Are you suffering from any contagious disease?

Yes

No

How your memory?		Sharp		Weak
Do you feel pain in the balls?		Yes		No

What is the structure of your semen? If there is any exam report pls.  Attach with this form

Do you take any alcoholic drinks ?

Yes

No

If yes

Regular

Occasional

Have you ever suffered from chicken pox ?		Yes		No
Are you suffering from Hydrosis		Yes		No

Have you ever been operated ?

Yes

No

If so details?

Is your partner suffering from any sexual problems ?

Yes

No

Have you ever been treated in past?

Yes

No

If so, What kind of treatment?

Homeopathic

Allopathic

Ayurvedic

Unani

If you are suffering from any other disease which is not mentioned write in detail in this box please.