NAME(required)

AGE (required)

SEX (required)

PLACE

MAIL ID(required)

CONTACT NO

TYPE OF JOB

EXERCISE

PHYSICAL ACTIVITY
NILLGOODOVER EXERTION

CONSTIPATION
YESNO

MARITUAL STATUS

DIET
VEGNON VEG

SMOKING
YESNO

ALCOHOL
YESNO

STRESS
YESNO

SLEEP
NORMALDISTURBED

TRAUMA/INJURY TO PELVIC REGION
YESNO

MASTURBATION(in past)
YESNO

MASTURBATION(in present)
YESNO

ANY TYPE OF SURGERY

ERECTILE DYSFUNCTION
YESNO

PRE MATURE EJACULATION
YESNO

NIGHT FALL
YESNO

ANY TYPE OF MEDICINE CONSUMPTION

ANY BLOOD TEST REPORT

URINE ANALYSIS

LIPID PROFILE

SEMEN ANALYSIS

DISEASES
HEARTHYPERTENSIONDIABETESDEPRESSIONADDICTIONTHYROIDNEVOUS DISORDER

DISEASES DETAILS