World's First & Only Ayurvedic Urology Center
Ayurvedic Urology Center
+91 94233 80111
info@cureurethralstricture.com
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Online Consultation
Fill out the form below to book an online consultation with our expert Ayurvedic practitioners.
Personal Information
Name of the Patient
*
Date of Birth
Gender
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Male
Female
Address
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Phone
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Email
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Occupation
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Marital Status
*
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Married
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Case History
Sr.
Signs & Symptoms
YES (Y) / NO (N)
Duration
1
Frequency of urination
Y
N
2
Urgency
Y
N
3
Nocturia (Frequency during the night)
Y
N
4
Incontinence (Leakage of urine)(Urge / Stress / Nocturnal)
Y
N
5
Pelvic pain
Y
N
6
Incomplete emptying of the bladder
Y
N
7
Episodes of near retention
Y
N
8
Voiding small volume of urine
Y
N
9
Spraying / Double streaming
Y
N
10
Haematuria (Blood in urine)
Y
N
11
Burning & Dysuria
Y
N
12
Straining
Y
N
13
Hesitancy (Difficulty in starting flow)
Y
N
14
Poor flow of urine
Y
N
15
Dribbling of urine
Y
N
16
Intermittency (Interrupted flow)
Y
N
17
Haemospermia (Blood in the semen)
Y
N
18
Retrograde ejaculation (semen doesn't express during sexual activity)
Y
N
19
Reduced ejaculation force
Y
N
20
Discharge from the urethra
Y
N
21
Pain in the Scrotum / Testicles
Y
N
22
Dyspareunia (Painful sexual activity)
Y
N
23
Fever with chills & rigors
Y
N
Other Information
Other Complaints/Comments
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