Sex Problem Female : Treatment Form
Fill all the fields, if you want complete treatment
   
* Name
* E-mail
*Address
*City
*State
*Zip Code
* Country
* Mobile Number
* Phone Number
* Fax Number
   
Age
Weight
Height
Occupation
Are you married
If so, How long 		Yes No
Mention the reason your pregnancy failures
For how long your pregnancy last
Do you have child bearing problem Yes No No If so, how long?
Mention if you not get pregnancy at all
How about your mensuration period Normal Early Delayed
If early or delayed, mention the days
How many days mensuration last
Do you feel extreme pain at the time of mensuration Yes No
Do you feel uncomfortable or pain while passing urine Yes No
Do you feel extra pain at the time of (intercourse) union with your male companion Yes No
Is your husband suffering from any sexual disorder Yes No If so specify?
Do you feel irritation in both legs and hands Yes No
Do you smoke Yes No
Do you take alcoholic drinks Yes No
What kind of medicines you have taken earlier.
Specify whether you have done the following tests:
1. Fallopian Tubes Closed or Damaged Either Both Or One
2. Uterus Whether there is tumours or infection Yes No
3. Ovaries Whether the mouth closed Yes No
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