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Name of the Patient *
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Age *
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(Yrs.)
Weight (Kg)
Height (e.g. 5 feet, 7 inches)
Profession
Email *
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Complete Postal Address
City
State
Zip
Country *
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1. Marital Status
2. If married,
(a) Date of Marriage
(b) No. of Children
(c) Age of eldest child
(d) Age of youngest child
(e) At present, are you living with your wife ? 
3. Describe your main problems for which you
want to seek our advice. *

A value is required.
4. How is your physique ?
5. How is your appetite ?
6. Do you have constipation ?
7. Type of food that you eat.
8. Do you consume tobacco in any form ?
9. Are you addicted to any other intoxicant
(e.g., liquor/wine etc.) ?
10. Do you take excessive quantity of tea
or coffee ?
11. Do you suffer from sleeplessness ?
12. Do you suffer from excessive urination ?
13. Do you feel any irritation or burning
sensation while passing urine ?
14. How is the flow of urine ?
15. Do you suffer from Involuntary Urination ?
16. Do you suffer from Spermatorrhoea 
(i.e., involuntary flow of semen) ?
17. Do you have Nocturnal Emissions during 
sleeping, more than 2-3 times a month ?
18. Do you feel any pain or swelling in testicles ?
19. Do you suffer, or have you ever suffered
from any venereal disease (Syphilis / 
Gonorrhoea) ?
20. Does any mucous (pus / fluid) pass out with urine ?
21. Do you face the following problems :
(a) Lack of erection
(b) Lack of stiffness
(c) Premature ejaculation
(d) Lack of sex desire
22. Is there any deformity in the male organ ?
23. If yes, clarify. Systolic / Diastolic
24. Do you suffer from High Blood Pressure ?*
Please Select yes / no.
25. If yes, mention your blood pressure.
26. Are you suffering from Diabetes ?*
Please Select yes / no.
27. If yes, mention Blood Sugar :

28. Have you suffered from any disease earlier ?
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
 
   
Female Problems
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

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