男性荷尔蒙健康调查表.doc

(完整版)男性荷尔蒙健康调查表
Health Test Form
健康调查表
Your Personal Date个人资料:
Family Name姓： Guveb Name名： Nationality国籍： □Male男
ID Card No身份证号码： □Married已婚 □Single未婚
Date of Birth出生日期： Y年 M月 D日 Your Job职业: Tel电话：
Mail Address邮寄地址：

Please tick the appropriate box“√”by the following guided of Health Advisor
请在健康顾问指引下在适当方格上“√”号
1、Lacks the masculine hormone the performance缺少男性荷尔蒙的表现：
□潮热、出汗Hot fluses,khan Road □易激动、暴躁Easy to be excited, to be hot tempered
□性生活频率减少、性欲减退The sex life frequency reduces， the sexual desire decrease
□胸闷、气短Chest tightness,shortness of breath
□厌恶性生活Loathing sex life □阴毛及腋毛脱落Armpits and pubic hair shedding
□失眠多梦Insomnia dreams □脱发Alopecia
□乏力、畏寒The asthenia， the fear are cold □记忆力减退Memory decrease
□食欲不振Having a poor appetite □注意力不集中The attention is not centralized
□焦虑不安Hot and bothered □肌肉松驰Muscle relaxants
□视力、听力减退Vision， hearing decrease
□尿频、尿急Frequent micturition, urgency of urination □肥胖Obese
□阴茎勃起角度小The penis erection angle is small
□阳萎、早泄Impotence, premature ejaculation □射精不畅Semination impeded
□缺钙、抽筋Lacks the calcium， the convulsions □经常性便秘Regular constipation
□高血脂、高血压、高血糖High blood fats, hypertension, hyperglycemia
□忧郁症Menopausal depression
2、Skin type皮肤状况：
□肤色灰暗、松驰Dark color,relaxation □黑斑Black spot □干燥Dryness
□微血管扩张Blood capillary expansion □毛孔粗大Pouch □面疱Face bleb
□皱纹增多Increased wrinkles □敏感Sensitiveness □眼袋Coarse pore
□油脂分泌不均Oil uneven secretion □黑眼圈Black eye
3、Favorable food喜好食物：
□油炸Fried foods □辣物Hot foods □清淡Insipid foods
□酒类Wines □肉Meats □咖啡Coffee
□海鲜Seafood □蔬菜Vegetables □水果Fruits
4、Spirit精神
□悠然Ieisurely □急燥Impationt □用脑过多Overuse of brain
□神经质Nervous temperament □开朗Breezy □忧闷Gloomy
5、Did you ever experienced allergic reacion to the following objects?
您对下列品项是否曾有过反映?
□高蛋白食物Protein′s foods □海鲜Seafood □花粉Flower powder
□药物Medicine □膏药Plaster □化妆品Cosmeties

男性荷尔蒙诊断表
调查期间身体变化表及自检
次数
日期
做后症状反应
签字

注：对以上治疗效果是否满意 签字：