Do you urinate frequent? YesNoOccasionally
Is there any urgency to urinate? YesNoOccasionally
Have you experienced involuntary urination (Dribbling of drops without knowledge/dribbling after urination?) YesNoOccasionally
Does it burn when you urinate or is it painful when you urinate? YesNoOccasionally
How many times do you wake up to urinate at night NoneOnceMore Than Once
Do you have a frequent Urinary Track Infections? YesNoOccasionally
Does it pain when you ejaculate or when you have an erection? YesNoOccasionally
Have you got any investigations done, like an ultrasound, or PSA (If yes, then please mention the details of the reports in the ‘more information’ column at the end of the questionnaire) ?YesNo
Are you already a patient with Dr. Manoj's Homeopathy? If yes then please give your Registration number in the ‘more symptoms’ column at the end of the questionnaire.YesNo
Name:
Email Address:
Contact Number:
Location/City:
Gender:MaleFemale
Age:-Select-1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months12 Months234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798
More Symptoms: