Male Problem Form

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Male Problem Form

Please answer the following:

Your Name
*

Age
*

Weight (Kg)
*

Mobile Phone No
*

Email
*

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

Do you consume tobacco in any form?
*

Yes

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

Yes

Do you take excessive quantity of tea or coffee?
*

Yes

Do you suffer from sleeplessness?
*

Yes

Do you suffer from excessive urination?
*

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Have you suffered from any disease earlier?
*

Yes

Any other problem that you might like to state
*

yes

Do you feel any pain or swelling in testicles?
*

Yes

Do you face the following problems?
*

yes

Lack of erection
*

yes

Lack of stiffness
*

yes

Premature ejaculation
*

yes

Lack of sex desire
*

Yes

Is there any deformity in the male organ?
*

Yes

------If yes, clarify *

Systolic

Dystolic

Do you suffer from High Blood Pressure?
*

Yes

Are you suffering from Diabetes?
*

Yes

Send your medical report on this email : hakeem@ajmalhealth.com

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