NAME(required)

AGE and SEX (required)

PLACE

MAIL ID(required)

CONTACT NO

TYPE OF JOB

PHYSICAL ACTIVITY

CONSTIPATION

MARITUAL STATUS

DIET

SMOKING

ALCOHOL

STRESS

SLEEP

TRAUMA/INJURY TO PELVIC REGION

MASTURBATION(in past)

MASTURBATION(in present)

ANY TYPE OF SURGERY

ERECTILE DYSFUNCTION

PRE MATURE EJACULATION

NIGHT FALL

ANY TYPE OF MEDICINE CONSUMPTION

ANY BLOOD TEST REPORT

SEMEN ANALYSIS

DISEASES

DISEASES DETAILS

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