FREE ONLINE CONSULTATION FORM

We understand the privacy concerns related to patient and that is why we have placed this consultation form. Anyone can discuss their sexual problems using the following form:

NAME(required)

AGE (required)

SEX (required)

PLACE

MAIL ID(required)

CONTACT NO

TYPE OF JOB

EXERCISE

PHYSICAL ACTIVITY

CONSTIPATION

MARITUAL STATUS

DIET

SMOKING

ALCOHOL

STRESS

SLEEP

TRAUMA/INJURY TO PELVIC REGION

MASTURBATION(in past)

MASTURBATION(in present)

ANY TYPE OF SURGERY

ERECTILE DYSFUNCTION

PRE MATURE EJACULATION

NIGHT FALL

ANY TYPE OF MEDICINE CONSUMPTION

ANY BLOOD TEST REPORT

URINE ANALYSIS

LIPID PROFILE

SEMEN ANALYSIS

DISEASES

DISEASES DETAILS

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