Impotency Treatment Form
Fill all the fields, if you want complete treatment

This treatment form is formulated to help you to specify your problems better & this also enable us to analyze your ailments properly. Our panel of Hakeems personally go through every e-mail & 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. Impotency is a curse on human race, we determine to eradicate this with our effort and medicine. So as human relationship will be happier and healthier.

   
* 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 Sleep Emission 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
Appendicitis Yes No
Contagious disease Yes No
Hydrocele
Yes No
   

Blood pressure
If yes,

Yes No
HBP LBP

Do you feel sexually aroused during formal interaction with a femalel (If you are not married)

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