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Medical History and Appointment

If you plan to come to our 3D Prostate Clinics for testing and treatment, you need make an appointment in advance. In order to advise you regarding your condition and appointment scheduling, we need to know more about your condition. Please fill out the questionnaire below as fully as poss ible and send it to us. All your information will remain confidential.

1) 1) What is your name, age, occupation, contact number, email, city and country you currently live in?

2) Do you suffer from one or more of the following conditions: prostatitis, enlarged prostate, benign prostatic hyperlasia (BPH), prostate cancer, prostate blockage, prostate calcification, urethritis, epididymitis, seminal vesiculitis, sexually transmitted disease (STD) among others? How long have you suffered from these condition(s)?

3) What are your symptoms of prostate disease and genitourinary infections; such as urinary frequency, urgency, urinary stream hesitancy, dysuria, burning, pain, itching, and erectile dysfunction, and more? How long have you had these symptoms?

4) What medical tests and examinations for prostate disease and genitourinary infections have you had done? Do you have any of these tests and reports? What were the results?

5) Have you had any surgery on your prostate or epididymis?

6) What medications have you taken in the past and for how long? What medications are you currently taking and for how long?

7) What medical treatment have you received for prostate disease and genitourinary infections? What were the treatment results?

8) Do you suffer from depression. If yes, how long have you had depression, what is the severity level and are you taking any anti-depression and/or anti-anxiety medications?

9) Please describe your overall health and include any other medical issues that you currently have.

10) Did your sexual partner ever have a genitourinary infection? If yes, please explain in detail.

11) Do you want to be cured by 3D treatment? Do you intend to come to our 3D Prostate Clinics for testing and treatment and if so when? Do you have any questions about our treatment process; cost, treatment, safety, or anything else?

12) If you plan to come to one of our 3D Prostate Clinics for testing and treatment, please advise us at least one week in advance with your arrival date and time, flight details, whether you would like us to make a hotel reservation for you, arrange a free airport pickup and provide a professional translator.

(Thank you for answering the questionnaire, your reply will be sent to our mailbox: )