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MALE CONSULTATION FORM

* fields are mandatoryDetails Information
Name of the Patient *  
Age *  
Weight  
Height  
Profession * 
Email ID *  
Complete Postal Address  
City *  
State * 
Pin Code  
Marital status   Married     UnMarried
Describe Your Problem for which you want to seek advice?  
Is there any past history have you suffered from any disease earlier?  
Do you suffer from High Blood Pressure   Yes     No
Are you suffering from diabetes?   Yes    No
How is your physique?   Fat    Slim     Average
How is your motion  Constipation    Loose    Normal
Do you feel excessive urination   Yes   No
Do you feel any irritation or burning while passing urine   Yes    No
How is the flow of urine   Smooth   Restricted
Do you suffer from invotuntary urination   Often   Sometimes   Never
Dietery habbit   Veg    Non Veg   Mix
Do you cousume liquor or wine   Yes    No
Do you suffer from sleeplessness  Yes    No
Are you addicted to any other intoxicant (eg: wine,alcohol/smoking)   Yes   No
do you suffer form spermatorrhea (involuntary flow of semen)   Often   Sometimes    Never
Do you have nocturnal emissions during sleeping more than 2-3 times month   Often   Sometimes    Never
Do you feel pain or swelling in testicles   Yes   No
Does any mucous (pus/fluid) pass out with urine   Often   Sometimes    Never
Do you face the following problems((A) LACK of erection)   Often   Sometimes    Never
Do you face the following problems((B) Lack of stifffess)   Often   Sometimes    Never
Do you face the following problems((C)Premature ejaculations)   Often   Sometimes    Never
Do you face the following problems((E) Lack of sex desire )   Yes   No
Is there any deformity in the male organ   Yes   No
If you have recently undergone a medical check-up pertaining to blood,urine,stool,sputum,any X-ray/ultrasonography,please mention the information here  
Any other problem that you might like to state  
   

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Baqai Healthcare

3070,PARKING GOLCHA CINEMA,DARYA GANJ,NEW DELHI, Darya Ganj, - 110002, India

Mobile : +91-9811436517, +91-9899641514

Phone : +91-11-23262757

Call Us : 08048771135

E-mail : baqaidawakhana@gmail.com



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