AR-Labs.com :: A Reputable Herbal Younani Medicine Manufacture Company Free Consultancy for Male and Female Contact Us
Company Introduction Company Products Free Home Remedies
 
Patient Name :

Male Consultation

Male Consultation

Age : Years
Weight : Kg
Height :
Profession :
Status :
E-mail :
Postal Address :  
City :  
State :  
Zip :  
Country :  


# indicates only for Married patients.

Date of marriage? dd/mm/yyyy       #

 

Number of children? #  
Age of eldest child Year (s)  #  
Age of youngest child Year (s) #  
How is your physique? Fat Slim Average
How is you appetite? Good Poor
Do you have constipation?  Yes No  
Type of food that you eat Vegetarian Non-Veg  
Are you addicted to any other intoxicant (liquor/wine etc.)? Yes No  
Do you suffer from sleeplessness? Yes No  
Do you take excessive quantity of tea or coffee? Yes No  
Do you suffer from excessive urination? Yes No  
Do you feel any irritation or burning sensation while passing urine? Yes No  
Is your Urine color yellowish? Yes No  
Does any mucus (fluid/pus/white discharge) pass out in urine? Yes No  
Are you having problem of white discharge (leucorrhoea) in particular? Yes No  
How is the flow of urine?  Restricted Smooth  
Do you suffer from Involuntary Urination? Yes No  
Do you suffer from Spermatorrhoea? Yes No  
Do you have any nocturnal emissions, more than 2-3 times a month? Yes No  
Do you feel any pain or swelling in testicles?  Yes No  
Do you feel palpitation of heart or pain in the chest or breathlessness during physical exercise? Yes No  
Is there any history of hereditary disease in the family? Yes No  
If yes then mention it
Do you suffer or have you ever suffered from any venereal disease (Syphilis, Gonorrhoea)? Yes No  
Are you diabetic? Yes No  
If yes, mention sugar level in blood
in urine

   
Are you a patient of Hypertension? Yes No  
If yes, mention your blood pressure    
Do you face any problem in your married life such as:      
Lack of erection? Yes No  
Lack of stiffness? Yes No  
Premature ejaculation? Yes No  
Lack of sexual desire? Yes No  
Any other problem that you might like to state.

Important
If you have recently undergone a medical check-up pertaining to Sputum, phlegm, blood, urine or any X-ray, please mention the related reports.
 

 
   
   
   
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