For Men Men's Diagnostic Form Please provide complete and accurate information so that your condition can be assessed properly and appropriate guidance can be provided. Basic Information Name Father's Name Age Date Mobile Number Email Country City Full Address Occupation / General Activity General Health What is your body type? SlimAverageOverweight Height ShortAverageTall Is your work mainly physical or mental? PhysicalMental Do you regularly experience any of the following conditions? Cold / FluCoughHeadacheWeakness / FatigueDiabetesHigh Cholesterol / TriglyceridesHigh Uric AcidNone How is your memory? —Please choose an option—GoodFairPoor How is your eyesight? —Please choose an option—GoodFairPoor How is your sleep? —Please choose an option—PeacefulRestless Blood Pressure —Please choose an option—HighNormalLow If you are producing phlegm, please provide details Sleep, Temperament and Habits Have you ever fainted? YesNo How many hours do you usually rest? 4–6 hours6–8 hours8–10 hours Are you currently experiencing any unusual stress or worry? YesNoSomewhat Which of the following do you regularly use? TeaCoffeeCigarettesNaswar / Smokeless TobaccoAllNone What is your natural temperament? —Please choose an option—ColdHotPhlegmaticBiliousNot Sure Which type of foods affects you adversely? —Please choose an option—HotColdNot Sure Heart, Breathing and Digestion Does your heartbeat increase with more than usual exertion? YesNo Do you become short of breath while walking or climbing stairs? YesNo Do you usually experience sour or foul-smelling belching? YesNo Do you have a good appetite? YesNo Do you experience heartburn or acidity? YesNoSometimes Do you frequently eat rich, oily foods or fast food? Yes, OftenNoSometimes How many meals do you eat per day? —Please choose an option—OnceTwiceThree TimesFour Times Do you commonly experience constipation? —Please choose an option—YesNoSometimes How many bowel movements do you have per day, and at what times? What is the usual color and consistency of your stool? Is it loose or hard? Urination, Surgery and Family Medical History How many times do you urinate during the day and night? What is the usual amount of urine? Select any relevant past or family medical issue Urinary ProblemSurgeryFamily Medical ConditionNone If applicable, describe what happened, when it occurred, and who was affected For Married Men Are you satisfied with your marriage? YesNoSomewhat How long have you been married? How many children do you have, and what are their ages? Male Sexual Weakness / Men's Health Issues Do you have any of the following penile concerns? CurvatureSmall SizeWeaknessNone How would you rate your sexual strength? Very GoodGoodFairPoorNone at All Does the penis shrink in cold water? YesNo What is the consistency of your semen? ThickThin Do you experience any of the following? Nocturnal Emissions / Wet DreamsLow LibidoNone Do you experience pain in the penis or muscles? YesNoSometimes Do you experience back pain? YesNoSometimes Do you experience premature ejaculation? YesNoSometimes How frequently do you experience nocturnal emissions? Do you notice drops after urination? SemenPre-ejaculateUrineNone Do you experience any discharge after urination? YesNo Have you experienced persistent nocturnal emissions? YesNo Have you ever masturbated? YesNo Do you have syphilis? YesNo Do you have gonorrhea? YesNo Describe your men's health condition or symptoms in detail Important Note for the Patient What is your estimated budget for one month of medication? Upload any relevant medical reports I confirm and declare that I have completed this form carefully, thoughtfully, and to the best of my knowledge.
