Name：           *Age：  *　 Birthplace： 　 National： 　 Professional：

Literacy： 　 Zip：   E-mail ：

Workplace：   Area code / Phone：  *

Address：

History：    

Marriage History：     Year 　Marriage times： Times　Intermarriage：Yes No 　 Contraception：Yes No

Sexual history： Sexuality：Have Occasional Without 　 Erectile：Can The need to stimulate Not

Hardness of erection： Strong Weak General   Frequency of sexual intercourse： Day Times

Ejaculation action：strong Inability No ejaculation 　　

Involuntary erection morning：Yes Without  Semen：Yes Without

Sex life before erectile into the vagina before he weakness：
Yes Not Other  

Masturbation History：There Occasional Without

Family history:：
whether congenital diseases, genetic diseases, described in the fertility of our brothers and sisters

Over the past if they are suffering too：mumps 、Orchitis 、Vesiculitis 、Epididymitis 、 TB 、Hyperthyroidism 、Gonorrhoeae 、Condyloma 、Syphilis 、Prostatitis 、Diabetes 、Hepatitis 、Gastric ulcer 。

Whether or genital trauma ：

Whether the urinary system and reproductive system surgical history：

Drinking History： Annual daily traffic Ml, degrees Smoking history Years, the daily Support

Development:：Good Medium Somewhat less Somewhat less 　 Nutrition：Good Medium Somewhat less Poor
 Of sleep：difficulty falling asleep Dreamy       Skin：superficial lymph nodes is No
Thyroid：Normal Swollen            Oral：dental caries is the No

Breast:：uplift Paletted Nipple discharge Heart Rate： Times/min
Scrotum：eczema Without     Fistula：Yes Without
Pubic hair：thick Scarce Absent Foreskin：too long Phimosis
Testis ：both sides of the other large Hard Soft Soft and flexible Tenderness

Penile deformity：Yes No Erectile Length： Cm     rubber swelling： Yes Without

TCM Diagnosis:

Testicular pain     Scrotum wet    Scrotum itching    Scrotum hot and humid    Genital odor    尿道刺疼  
Turbid urine    Force with inflammatory bowel secretions urethra Hands and feet heart fever    Multi-night, Khan  Insomnia    
Dreamy         Xi drinking thirst    Thirsty to drink instead of Xi Xi cold      Xi hot drinks     Poor appetite  
White urine      Yellow urine      Dark yellow urine    Frequent nocturnal     Urine Sauvignon   After I urinate Lek endless  
Constipation         5 o'clock every morning to go to stool accompanied by abdominal pain Upset irritability     Throat mouth pain   Severe hair loss   
Mild hair loss     Sparse hair     White hair      Unclear, as the object   Bloody eyes    Binocular stained    
Ears ringing in the ears    Two zygomatic redness, such as Black eyes    Pharyngeal itch and cough   Chest tightness, short-winded  Stomach bloating  
Abdominal pain     Waist pain    The left kidney area pain   Right kidney area pain Back apathetic   

Tongue: Lingual cracked      Tongue side of teeth and India     Every day I have to brush fur        White thick fur        Huang Hou-fur

Pulse: Strong pulse    Weak pulse     Floating pulse (such as water driftwood)  Pulse Shen     Pulse string (for example, by strings) Pulse-slip (such as disk Ball)
              Pulse Bo 50 to 60 times per minute Bo pulse 60-80 times per minute Bo pulse 80 to 100 times per minute