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 depression2、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 eye3、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Fruits4、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Gloomy5、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Proteins 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：