Sex Questionnaire - HomeopathicVibes

Call Us: (408)-737-7100
Our Address: 940 E El Camino Real, Sunnyvale, CA - 94087 | 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538

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Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

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Conditions We Treat

Skin Conditions
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Sex Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Email *

Marital status

Married
Single
Widow
Divorced
Separated

Do you feel passing of semen or any abnormal fluids

Before Urination
After Urination
After Stool

Does the discharge of semen occurs during sleep?

Yes
No

Do you feel your penis is bent or loose towards the left side?

Yes
No

Do you get perfect erection before intercourse?

Yes
No

Do you feel weakness after the intercourse?

Yes
No

Are you suffering from premature ejaculation?

Yes
No

Do you ever had the habit of masturbation

Yes
No

What is your usual duration of intercourse with current partner/wife?

Less than 5 minutes
More than 5 minutes
More than 10 minutes

What was your usual duration of intercourse with previous partner if any?

Do not apply
Less than 5 minutes
More than 5 minutes
More than 10 minutes

If so, since how long?

Are you a

Vegetarian
Non Vegetarian?

Which types of food do you like?

Spicy
Mild?

Do you have Gastric Problem ?

Yes
No

Do you have constipation?

Yes
No

Did you ever suffered from

Syphilis
Gonorrhea
UTI

What is the approx. length of your organ?

Before erection?

After erection?

How many times a month you do intercourse?

How many times night discharge occurs in a week?

Do you read vulgar & obscene literature?

Yes
No

Do you watch vulgar & obscene movies?

Yes
No

Do you imagine romantic fantasies

Yes
No

Does your underwear get wet when you see nude photographs

Yes
No

Are you suffering from blood pressure

Yes
No

If so, whether it is?

High
Low

Do you suffer from heart problem

Yes
No

Do you sleep well

Yes
No

How many times you wake up to urinate during night?

I don’t wake up
1-3 times
4-6 times
More than 6 times

Do you play Homo sex (Man to Man)

Yes
No

Do you exercise daily

Yes
No

Do you feel pain after urination ?

Yes
No

Are you suffering from diabetes?

Yes
No

Have you ever had any road accidents?

Yes
No

If so, please furnish the full details

Do you take your food timely?

Yes
No

Do you take hot milk at bed time?

Yes
No

Is your wife older than you?

Yes
No

If so how many years?

Did you eve had any contagious disease?

Yes
No

How about your memory?

Sharp
Weak

What is the structure of your semen?

Thick
Watery

Did you ever took any street drugs?

Regular
Occasionally
Never

Do you take any alcoholic drinks?

Daily
Occasionally
Never

Did you ever suffered from Hydrocele?

Yes
No

Did you ever suffered from Cystocele?

Yes
No

Did you ever suffered from Hernia?

Yes
No

If any of the have been operated upon

Yes
No

If so details

Your partner has any sexual problem?

Yes
No

Have you ever been treated in past?

Yes
No
Homeopathic
Allopathic
Ayurvedic
Others

If so details

How long?

What are your expectations from our treatment?

I don’t expect good results.
I expect good results.
I would be happy if I improve.
I am confident.

Are you willing to make changes to your life style or diet modifications?

I can not change my lifestyle.
I have tried nothing works for me,
I am willing to change my lifestyle if needed.
I am willing to do what ever is needed to get results,

Email

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

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Weekdays: 10:00 am - 6.00 pm
Weekend: By Appointment only

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