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Male Infertility Form

male-form

The following Performa is formulated to help you to specify your problems correctly & this enable to analyze your ailments accurately. Chief Executive of Tibb-e-Islami Dawakhana (Regd.) Professor Hakim Dilshad Hussain Tabassum personally goes through every e-mail & a panel of expert Hakims review every individual case. Our unani medicines has a legacy of more than 1000 years of tradition & knowledge and our medicines are prepared strictly in accordance with the age old medical scripts, texts & manuals of unani practice with the help of modern scientific tools. Now world renowned western doctors has conceded that where modern medicine failed to cure, there “unani herbalism” steps in to cure the incurable. Today unani medicine is recognized worldwide by World Health Organization (WHO) as one of the alternative system of medicines & forms an integral part of national health care delivery system. For those who are unable to find a solution, we show them right direction through our valuable consultation. We remind you that the root cause of all sexual disorders lies in the ignorance, bad habits, wrong life styles & unnatural sex acts of younger days. These destroy one’s own body & health. Our treatment will certainly help you to live a long life free from these diseases.
You are encouraged to fill in the form without any hesitation or shyness, as it remains confidential with us….

Your Name
Occupation
E-mail
Address
City
State
Zip Code
Country
Age years
Weight Kg
Height
Do you feel passing of semen Before Urination
After Urination
After Stool
Does the discharge of semen occurs during sleep YesNo
Do you feel your penis is bent or loose towards the left side YesNo
Do you feel weakness after the intercourse YesNo
Are you suffering from premature ejaculation YesNo
Do you get perfect erection before intercourse YesNo
What is your duration of intercourse
Do you have the habit of masturbation YesNo
If so, since how long
Are you VagetarianNon-vagetarian
Which type of food do you like SpicyMild
Do you have Gastric Problem YesNo
Do you have constipation YesNo
Are you suffering from SyphilisGonorrheaNothing
What is th lenght of your organ Before erection
After erection
How many times you urinate during night Times
Do you have ever sex with man YesNo
Do you excersice daily YesNo
Do you feel pain after urination YesNo
Are suffering from diabetes YesNo
Have you ever met with fatal road accidents
If so, please furnish the full details.
Do you take your food timely YesNo
Do you take hot milk at bed time YesNo
Is your wife older than you YesNo
If so how many year Year
Are you suffering from any contagious disease YesNo
How about your memory SharpWeak
What is the structure of your semen ThickWatering
Do you take any alcoholic drinks RegularOccasionalNaver
Are you suffering from Hydrocele YesNo
Have you ever been operated YesNo
If so details
Is your partner suffering from any sexual problem YesNo
Have you erver been treated in past YesNo
If so, What kind of treatment
HomeopathicAllopathicAyurvedicUnani
Main Problem
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