| Husband's Name |
|
Age |
|
Education |
|
| Occupation |
|
| Wife’s Name |
|
Age |
|
Education |
|
| Occupation |
|
| Address |
|
| E-mail |
|
| MARRIED LIFE |
|
| Years |
|
| Husband |
|
| Wife |
|
| |
|
| COHABITATION |
Continous
Not Continous
Give Details
|
| SEXUAL HISTORY |
|
| About sexual life. Any problems specify |
|
MALE PARTNER |
| History of Past illness |
Tuberculosis
Mumps
Diebetes Mellitus
Infections of Genital Organs
Others . if others specify.
|
H / O drugs Intake (medicins) / Radiation etc
|
|
|
| H / O Any Surgery |
|
|
| Family
History
|
Detailed description of Father, Mother, Brothers,
Sisters, Uncles, Aunts, Grand parents, Children with their age and
any relevant diseases (Blood pressure, Diabetes, Hepatitis,
Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin
diseases etc.) |
|
| Personal
History
|
Sexual |
|
| |
Libido |
|
| |
Erectic |
|
| |
Ejaculatory |
|
Past History of Medical / Surgical Problem : |
|
| Sleep :
Nature, duration, position, dreams, snoring
etc
|
|
| MIND |
Patients
reaction towards the society, family and friends. Whether irritable,
anxious, tensed, suspicious, likes company of friends, brooding, |
| |
any
suicidal thoughts etc.
|
| |
Any
other details may be added
|
|
|
| Adiction |
|
Use of Contraceptive Methods : |
|
Previous obstretic history if any : |
|
| PATIENT AS A PERSON |
|
| |
|
| Urine
|
|
| |
|
| Motion |
|
| |
|
| Thermal |
|
| |
|
| CLINICAL EXAMINATION |
|
| GENERAL |
|
| PRODUCTIVE SYSTEM |
|
| PENIS |
|
| |
|
| SEMEN ANALYSIS |
|
| |
|
|
HORMONAL |
|
| |
|
OTHER TESTS |
|
FEMALE PARTNER |
| History of Past illness |
Any diseases which occurred in the past like
tuberculosis, hepatitis, typhoid, arthritis, blood pressure,
diabetes, HIV, cancer etc., may be described in detail in sequential
order. Also specify any other diseases from childhood down to the
present, chronologically with its nature, duration, severity, type
of treatment undergone etc. in detail.
If Patient has undergone any surgical intervention
for what and when |
|
| Family
History
|
Detailed description of Father, Mother, Brothers,
Sisters, Uncles, Aunts, Grand parents, Children with their age and
any relevant diseases (Blood pressure, Diabetes, Hepatitis,
Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin
diseases etc.) |
|
| Personal
History
|
Specify life situation
(Mile stones and other developmental details in
children) |
|
Menstrual History : |
|
| |
|
| Adiction |
|
| PATIENT AS A PERSON |
|
| |
|
| Urine
|
|
| |
|
| Motion |
|
| |
|
| Thermal |
|
| |
|
| SEXUAL HISTORY |
| About
sexual life. Any problems specify
|
|
|
Sleep
Nature, duration, position, dreams, snoring
etc |
|
| MIND |
Patients
reaction towards the society, family and friends. Whether irritable,
anxious, tensed, suspicious, likes company of friends, brooding, |
| |
any
suicidal thoughts etc.
|
| |
Any
other details may be added
|
|
|
PREVIOUS INVESTIGATION |
|
HORMONAL |
|
| |
|
OTHER TESTS |
|
| Other details |
|
The
payment should be processed through STATE BANK OF INDIA, BANK ACCOUNT DETAILS:SBT BANK AC/ NO :3909, KAU CAMPUS,VELLANIKKARA
Contact
the doctor for any other mode of payment. Fee includes consultation with
medicine. |
| |
|
| |
|
| |
|
