E-Consultation for Male Patient
Name of the Patient
Age
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
26 Years
27 Years
28 Years
29 Years
30 Years
31 Years
32 Years
33 Years
34 Years
35 Years
36 Years
37 Years
38 Years
39 Years
40 Years
41 Years
42 Years
43 Years
44 Years
45 Years
46 Years
47 Years
48 Years
49 Years
50 Years
51 Years
52 Years
53 Years
54 Years
55 Years
56 Years
57 Years
58 Years
59 Years
60 Years
61 Years
62 Years
63 Years
64 Years
65 Years
66 Years
67 Years
68 Years
69 Years
70 Years
71 Years
72 Years
73 Years
74 Years
75 Years
76 Years
77 Years
78 Years
79 Years
80 Years
81 Years
82 Years
83 Years
84 Years
85 Years
86 Years
87 Years
88 Years
89 Years
90 Years
91 Years
92 Years
93 Years
94 Years
95 Years
96 Years
97 Years
98 Years
99 Years
100 Years
Weight
20 KG
21 KG
22 KG
23 KG
24 KG
25 KG
26 KG
27 KG
28 KG
29 KG
30 KG
31 KG
32 KG
33 KG
34 KG
35 KG
36 KG
37 KG
38 KG
39 KG
40 KG
41 KG
42 KG
43 KG
44 KG
45 KG
46 KG
47 KG
48 KG
49 KG
50 KG
51 KG
52 KG
53 KG
54 KG
55 KG
56 KG
57 KG
58 KG
59 KG
60 KG
61 KG
62 KG
63 KG
64 KG
65 KG
66 KG
67 KG
68 KG
69 KG
70 KG
71 KG
72 KG
73 KG
74 KG
75 KG
76 KG
77 KG
78 KG
79 KG
80 KG
81 KG
82 KG
83 KG
84 KG
85 KG
86 KG
87 KG
88 KG
89 KG
90 KG
91 KG
92 KG
93 KG
94 KG
95 KG
96 KG
97 KG
98 KG
99 KG
100 KG
101 KG
102 KG
103 KG
104 KG
105 KG
106 KG
107 KG
108 KG
109 KG
110 KG
111 KG
112 KG
113 KG
114 KG
115 KG
116 KG
117 KG
118 KG
119 KG
120 KG
121 KG
122 KG
123 KG
124 KG
125 KG
126 KG
127 KG
128 KG
129 KG
130 KG
131 KG
132 KG
133 KG
134 KG
135 KG
136 KG
137 KG
138 KG
139 KG
140 KG
141 KG
142 KG
143 KG
144 KG
145 KG
146 KG
147 KG
148 KG
149 KG
150 KG
Height
4 Feet
4 Feet 1 Inch
4 Feet 2 Inch
4 Feet 3 Inch
4 Feet 4 Inch
4 Feet 5 Inch
4 Feet 6 Inch
4 Feet 7 Inch
4 Feet 8 Inch
4 Feet 9 Inch
4 Feet 10 Inch
4 Feet 11 Inch
5 Feet
5 Feet 1 Inch
5 Feet 2 Inch
5 Feet 3 Inch
5 Feet 4 Inch
5 Feet 5 Inch
5 Feet 6 Inch
5 Feet 7 Inch
5 Feet 8 Inch
5 Feet 9 Inch
5 Feet 10 Inch
5 Feet 11 Inch
6 Feet
6 Feet 1 Inch
6 Feet 2 Inch
6 Feet 3 Inch
6 Feet 4 Inch
6 Feet 5 Inch
6 Feet 6 Inch
6 Feet 7 Inch
6 Feet 8 Inch
6 Feet 9 Inch
6 Feet 10 Inch
6 Feet 11 Inch
7 Feet
Profession
Marital Status
Married Single
Email Address
Complete Postal Address
City
State/Province
Zip/Postal Code
Country
India United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and
Herzegowina Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African
Republic Chad Chile China Christmas Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican
Republic East Timor Ecuador Egypt El
Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France France,
Metropolitan French
Guiana French
Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatema
la Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Panama Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Lucia Samoa San
Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Afr icaSpain Sri Lanka St Helena Sudan Suriname Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab
Emirates United
Kingdom United
States Uruguay Uzbekistan Vanuatu Vatican City S tate Venezuela Viet Nam Virgin Islands
(British) Virgin Islands (US) Western
Sahara Yemen Zaire Zambia Zimbabwe Other-Not Shown
Date of marriage?
Number of children?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Age of eldest child
Age of youngest child
How is your physique?
Fat Slim Average
How is you appetite?
Good Poor
Do you have constipation?
Yes No
Type of food that you eat
Veg Non-Veg
Do you consume tobacco in any form?
Yes No
Are you addicted to any other intoxicant liquor/wine etc.)?
Yes No
Do you suffer from sleeplessness?
Yes No
Do you take excessive quantity of tea or
coffee?
Yes No
Do you suffer from excessive urination?
Yes No
Is your Urine color yellowish?
Yes No
Do you feel any irritation or burning
sensation while passing urine?
Yes No
How is the flow of urine?
Restricted Smooth
Do you suffer from Involuntary Urination?
Yes No
Does any mucus (pus/fluid) pass out with
urine?
Yes No
Do you suffer from Spermatorrhoea?
Yes No
Do you have any nocturnal emissions, more
than 2-3 times a month?
Yes No
Do you feel any pain or swelling in
testicles?
Yes No
Do you feel palpitation of heart or pain in
the chest or breathlessness during physical
exercise?
Yes No
Do you suffer or have you ever suffered
from any venereal disease (Syphilis, Gonorrhea)?
Yes No
Is there any history of hereditary disease
in the family?
Yes No
Mention it
Do you face any problem in your married
life such as
Lack of erection?
Yes No
Lack of stiffness?
Yes No
Premature ejaculation?
Yes No
Lack of sexual desire?
Yes No
Any other deformity, clarify
Are you diabetic?
Yes No
If yes, mention sugar
level in blood
in urine
Are you a patient of
Hypertension?
Yes No
If yes, mention your
blood pressure
Have you suffered from any disease earlier?
Yes No
If yes, name it
Important :
Any other problem that you
might like to state
