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Childlessness Male Treatment Form
Fill all the Fields, If you want Complete Treatment

*Name
*E-mail
*Address
*City
*State
*Zip Code
*Country
 
Age
Weight
Height
Occupation
Do you feel passing of semen Before Urination
After Urination
After Stool
   
Does the discharge of semen occurs during sleep Yes No
Do you feel your penis is bent or loose towards the leftside
Yes No
Do you feel weakness after the intercourse Yes No
Are you suffering from premature ejaculation Yes No
Do you get perfect erection before intercourse Yes No
What is your duration of intercourse
   
Do you have the habit of masturbation
If so , since how long

Yes No

   
Are your Vegetarian Nonegetarian
Which type of food do you like Spicy    Mild
Do you have Gastric Problem Yes      No
Do you have constipation Yes      No
Are you suffering from Syphillis Gonorrhea   Nothing
   
What is the length of your organ Before erection
After erection   
How many times night discharge occurs in a week
Do you read vulgar & obscene literature Yes No
Do you imagine romantic fantasies Yes No
Does your underwear get wet when you see nude photographs Yes No
   
Are you suffering from blood pressure
If so, whether it is 		Yes       No
Low BP HighB.P
   
Do you suffer from heart problem Yes       No
Do you sleep well Yes       No
How many times you urinate during night
Do you play Homosex (Man toMan) Yes       No
Do you exercise daily Yes       No
Do you feel pain after urination Yes       No
Are you suffering from diabetes Yes       No
   
Have you ever met with fatal road accidents
If so, please furnish the full details.
Do you take your food timely Yes       No
Do you take hot milk at bed time Yes       No
Is your wife older than you
If so how many years		 Yes       No
   
Are you suffering from any contagious disease Yes       No
How about your memory Sharp   Weak
What is the structure of your semen Thick    Watering
   
Do you take any alcoholic drinks Regular Occasional Never
Are you suffering from Hydrocele Yes       No
   
Have you ever been operated
If so details		 Yes       No
   
Is your partner suffering from any sexual problem Yes       No
   

Have you ever been treated in past             Yes       No
If so, What kind of treatment

Homeopathic Allopathic Ayurvedic Unani

 

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