男性荷尔蒙健康调查表.docVIP

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记忆力退Memory decrease食欲不振Having a poor appetite注意力不集中The attention is not centralizedHot 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