|
Date of marriage?
|
(DD/MM/YYYY) |
|
Number of children?
|
|
|
Age of eldest child
|
e.g. 3 Yrs.5 Months |
|
Age of youngest child
|
e.g. 3 Yrs.5 Months |
|
How is your physique?
|
|
|
How is you appetite?
|
Good
Poor |
|
Do you have constipation?
|
Yes
No |
|
Type of food that you eat
|
Veg.
Non-Veg. |
|
Do you consume tobacco in any form?
|
Yes
No |
|
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 |
|
Is your Urine colour yellowish?
|
Yes
No |
|
Do you feel any irritation or burning sensation while passing urine?
|
Yes
No |
|
How is the flow of urine?
|
Restricted Smooth |
|
Do you suffer from Involuntary Urination?
|
Yes
No |
|
Does any mucus(pus/fluid) pass out with urine?
|
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 |
|
Do you suffer or have you ever suffered from any venereal disease (Syphilis, Gonorrhoea)?
|
Yes
No |
|
Is there any history of hereditary disease in the family?
|
Yes
No |
|
Mention it
|
|
|
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 deformity, clarify
|
|
|
Are you a patient of Hypertension?
|
Yes
No |
|
If yes, mention your blood pressure
|
|
|
Are you diabetic?
|
Yes
No |
|
If yes, mention sugar level in blood
|
|
|
in urine
|
|
|
Have you suffered from any disease earlier?
|
Yes
No |
|
If yes, name it
|
|
