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MALE CONSULTATION FORM

Products

Baqai Artho-Guard Oil
Baqai Halwa Gheekwar
Baqai Hazim Powder
Baqai Hazim Chatni
Baqai Healto Care Tonic
Baqai Herbal Syrup
Baqai Herbal Tablets
- Baqai Consti Care Tablets
- Baqai Jiryani Go Tablets
Baqai Khamira Dimagi Sona Chandi
Baqai Musli Aloe Vera Power Prash
Baqai Obe-Fit Pills
Baqai Shilajeet

Baqai Healthcare

3070,PARKING GOLCHA CINEMA,DARYA GANJ,NEW DELHI, Darya Ganj, - 110002, India

Call Us : View Mobile Number

Phone : +91-11-23262757

E-mail : baqaidawakhana@gmail.com

* fields are mandatoryDetails Information
Name of the Patient *
Age *
Weight
Height
Profession *
Email ID *
Complete Postal Address
City *
State *
Pin Code
Marital status	Married UnMarried
Describe Your Problem for which you want to seek advice?
Is there any past history have you suffered from any disease earlier?
Do you suffer from High Blood Pressure	Yes No
Are you suffering from diabetes?	Yes No
How is your physique?	Fat Slim Average
How is your motion	Constipation Loose Normal
Do you feel excessive urination	Yes No
Do you feel any irritation or burning while passing urine	Yes No
How is the flow of urine	Smooth Restricted
Do you suffer from invotuntary urination	Often Sometimes Never
Dietery habbit	Veg Non Veg Mix
Do you cousume liquor or wine	Yes No
Do you suffer from sleeplessness	Yes No
Are you addicted to any other intoxicant (eg: wine,alcohol/smoking)	Yes No
do you suffer form spermatorrhea (involuntary flow of semen)	Often Sometimes Never
Do you have nocturnal emissions during sleeping more than 2-3 times month	Often Sometimes Never
Do you feel pain or swelling in testicles	Yes No
Does any mucous (pus/fluid) pass out with urine	Often Sometimes Never
Do you face the following problems((A) LACK of erection)	Often Sometimes Never
Do you face the following problems((B) Lack of stifffess)	Often Sometimes Never
Do you face the following problems((C)Premature ejaculations)	Often Sometimes Never
Do you face the following problems((E) Lack of sex desire )	Yes No
Is there any deformity in the male organ	Yes No
If you have recently undergone a medical check-up pertaining to blood,urine,stool,sputum,any X-ray/ultrasonography,please mention the information here
Any other problem that you might like to state

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