0 Apply Online *ConsultantSelect Dr. A. Imran B.A.M.S Dr. A. Muhammad Husain B.N.Y.S *Patient Registration Number*Patient NameDate*Mobile*WhatsApp numberHow to you heard about usHow to you heard about us*AgePlace*Sex Male Female HeightheightWeight*Marital Status Single Married Divorced Separated Committed Smoking Yes No Occasionally Drinking Yes No Occasionally Tobacco Yes No Diabetes Yes No Blood Pressure Yes No Cholesterol Yes No Type of that you eat Veg Non veg Both Exercise Yes No Occasionally Body Type Fat Slim Average *Stress Yes No Deep fried foods Yes No Occasionally Sleep Sound Disturbed How many hours of sleepMicturition Normal Increased in frequency Pain while urinating Burning sensation No control over urination Does any pus or fluid pass out with urine Yes No *Semen volume 2ml More Do you have Nocturnal Emission during sleeping Present Absent Amount of water in take, mention in litters per day*OUR TREATMENT LISTSexual Weakness Erectile Dysfunction Low Sperm Count & Motility Premature Ejaculation Nocturnal Emission Venereal Diseases Lack Of Sexual Desire Leucorrhoea Asthma / Cough Dyspepsia/Indigestion Enlarged Prostate Genital Herpes Syphills Gonorrhea Genital Warts Dysuria/UTI Weight Loss Weight Gain Acne / Pimples Retrograde Ejaculation Delayed Ejaculation Spermatorrhoea General Debility Menstrual Cycle Regular Irregular No Leucorrhoea Present Absent No Do you feel any pain or swelling in testicles Yes No Do you suffer or have you ever suffered from any VD Yes No Has your problem developed Gradually Suddenly *Any past treatment taken*Duration of existing health problemAny history of surgeryOther health problemsAny past medical reportsPresent medications if any*Medicine collected from us Yes No *Prescription said himPatient response of collecting medicineOther Information Fields with (*) are compulsory.