Health Consult

Name *

First

Last

Email *

Gender *

Female
Male

Age *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you experience watery semen after ejaculation? *

Yes
No

Have you done semen analysis and culture? *

Yes
No

Reason for consultation *

Infertility
Infection
Other

Please specify *

What are some symptoms you have/observe *

If your case is hormone imbalance/ infertility please answer the following questions. How long have you been married?

Do you see your period regularly?

How many days does it flow?

What is the colour of the menstrual bleed?

Have you done any surgery in the past? Please indicate the type and year *

Attach file (Any available laboratory investigations eg. Abdominopelvic ultrasound scan and HSG scan, Urine culture and High Vaginal Swab test.)

Attach file (Any available laboratory investigations eg. add Semen Analysis)

The health information provided by Every Mother Matters is not intended
to substitute medical advice of your healthcare professional. If you have a
medical emergency, please call your physician.

Health Consult

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