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Libido Analysis Form
(Please enter the customer code that has been sent to you through email in the text box provided below "Customer Code")

* The fields are compulsory
* Email:

* Customer Code:

Penis Size

Small Medium Large

Scrotum

Are testicles descended in scrotum ?
Yes          No
Is there any swelling or pain in scrotum ?
Yes          No

Semen Quantity

More Less Moderate

Semen Quality

Bad odour Normal odour Bad odour with blood and pus

Erection

Hard No erection Moderate

Erection time

Less More Moderate

Others

More mental exertion Less mental exertion Moderate mental exertion
More physical exertion Less physical exertion Moderate physical exertion
Do you become more tensed about the present problem during sexual act?
Yes          No

If you have a rescent semen analysis report please mention (optional)


If you have any other chronic illness like diabetes , hypertension, bronchitis please give a brief history(optional)


History of present problem