Health Test Form
健康调查表
Y烤羊腿怎么腌制
our 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： &nb红枣桂圆粥
sp; □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：
Plea 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 flus,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 x life frequency reduces， the xual desire decrea
□胸闷、气短Chest tightness,shortness of breath
□厌恶性生活Loathing x 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 decrea
□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 decrea
□尿频、尿急Frequent micturition, urgency of urination □肥胖Obe
□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Dry芋头汤的做法
ness
□微血管扩张Blood capillary expansion □毛孔粗大Pouch □面疱Face bleb
□皱纹增多Incread wrinkles □敏感Sensitiveness □眼袋Coar pore
□油脂分泌不均Oil uneven cretion □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Overu 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
