* Name * E-mail *Address *City *State *Zip Code * Country * Mobile Number * Phone Number * Fax Number     Age Weight Height Occupation Is your semen passing Before Urination: After Urination: After Stool : How many times night discharge occurs in a week Penis bent or loose towards the leftside Yes No Feel weakness after the intercourse Yes No Suffering from premature ejaculation Yes No Get perfect erection before intercourse Yes No Duration of your intercourse Which type of food you take Spicy Mild Habit of masturbation , If yes, How long Yes No ,     Do you have the following ? Syphillis Gonorrhea Heart problem Yes No Appendicits Yes No Contagious disease Yes No Hydrocele Yes No Blood pressure Low High What do you feel whenever you see a girl (If you are not married) Comments