男性荷尔蒙健康调查表

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1、HealthTestForm健康调查表YourPersonalDate个人资料：FamilyName姓：GuvebName名：Nationality国籍：□Male男IDCardNo身份证号码：□Married已婚□Single未婚DateofBirth出生日期：Y年M月D日YourJob职业：Tel电话：MailAddress邮寄地址：Pleaseticktheappropriatebox“√”bythefollowingguidedofHealthAdvisor请在健康顾问指引下在适当方格上“√”号1、Lacksthemasculinehormonetheperformance缺少男性

2、荷尔蒙的表现：□潮热、出汗Hotfluses,khanRoad□易激动、暴躁Easytobeexcited,tobehottempered□性生活频率减少、性欲减退Thesexlifefrequencyreduces,thesexualdesiredecrease□胸闷、气短Chesttightness,shortnessofbreath□厌恶性生活Loathingsexlife□阴毛及腋毛脱落Armpitsandpubichairshedding□失眠多梦Insomniadreams□脱发Alopecia□乏力、畏寒Theasthenia,thefeararecold□记忆力减退Memo

3、rydecrease□食欲不振Havingapoorappetite□注意力不集中Theattentionisnotcentralized□焦虑不安Hotandbothered□肌肉松驰Musclerelaxants□视力、听力减退Vision,hearingdecrease□尿频、尿急Frequentmicturition,urgencyofurination□肥胖Obese□阴茎勃起角度小Thepeniserectionangleissmall□阳萎、早泄Impotence,prematureejaculation□射精不畅Seminationimpeded□缺钙、抽筋Lacksthe

4、calcium,theconvulsions□经常性便秘Regularconstipation□高血脂、高血压、高血糖Highbloodfats,hypertension,hyperglycemia□忧郁症Menopausaldepression2、Skintype皮肤状况：□肤色灰暗、松驰Darkcolor,relaxation□黑斑Blackspot□干燥Dryness□微血管扩张Bloodcapillaryexpansion□毛孔粗大Pouch□面疱Facebleb□皱纹增多Increasedwrinkles□敏感Sensitiveness□眼袋Coarsepore□油脂分泌不均Oi

5、lunevensecretion□黑眼圈Blackeye3、Favorablefood喜好食物：□油炸Friedfoods□辣物Hotfoods□清淡Insipidfoods□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Overuseofbrain□神经质Nervoustemperament□开朗Breezy□忧闷Gloomy5、Didyoueverexperiencedallergicreaciontothefollowingobjects?您对

6、下列品项是否曾有过反映？□高蛋白食物Protein′sfoods□海鲜Seafood□花粉Flowerpowder□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：