男性荷尔蒙健康调查表

男性荷尔蒙健康调查 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 depression 2、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 eye 3、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Fruits 4、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Gloomy 5、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Protein′s 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: