header image Professor Hakim Dilshad Hussain Tabssum (Gold Medalist) Ex-member: American Infertility Association (USA)
 
 

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  Yes No
Do you feel your penis is bent or loose towards the left side  Yes No
Do you feel weakness after the intercourse  Yes No
Are you suffering from premature ejaculation  Yes No
Do you get perfect erection before intercourse  Yes No
What is your duration of intercourse
Do you have the habit of masturbation  Yes No
If so, since how long
Are you  Vagetarian Non-vagetarian
Which type of food do you like  Spicy Mild
Do you have Gastric Problem  Yes No
Do you have constipation  Yes No
Are you suffering from  Syphilis Gonorrhea Nothing
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  Yes No
Do you excersice daily  Yes No
Do you feel pain after urination  Yes No
Are suffering from diabetes  Yes No
Have you ever met with fatal road accidents
If so, please furnish the full details.
Do you take your food timely  Yes No
Do you take hot milk at bed time  Yes No
Is your wife older than you  Yes No
If so how many year Year
Are you suffering from any contagious disease  Yes No
How about your memory  Sharp Weak
What is the structure of your semen  Thick Watering
Do you take any alcoholic drinks  Regular Occasional Naver
Are you suffering from Hydrocele  Yes No
Have you ever been operated  Yes No
If so details
Is your partner suffering from any sexual problem  Yes No
Have you erver been treated in past  Yes No
If so, What kind of treatment
 Homeopathic Allopathic Ayurvedic Unani
Main Problem
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