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MALE TREATMENT FORM
Fill in all the fields, if you want complete treatment

   
* Name
* E-mail
*Address
*City
*State
*Zip Code
* Country
   
Age
Weight
Height
Occupation
Is your semen passing Before Urination: After Urination: After Stool :
How many times night discharge occurs in a week
Penis bent or loose towards the leftside Yes No
Feel weakness after the intercourse Yes No
Suffering from premature ejaculation Yes No
Get perfect erection before intercourse Yes No
Duration of your intercourse
Which type of food you take Spicy Mild
Habit of masturbation ,
If yes, How long 		Yes No ,
   
Do you have the following ?
Syphillis Gonorrhea
Heart problem Yes No
Appendicits Yes No
Contagious disease Yes No
Hydrocele
 Yes No
Blood pressure Low High

What do you feel whenever you see a girl (If you are not married)
Comments

 


our clinic  about sex   childlessness    impotency   female sexuality   male sexuality  healthy sex   marriage   masturbation   night discharge   old age sex   orgasmic control  
penile abnormality   premature ejaculation   retarded