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PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT
PERSONALIZED NUTRITION PLAN

This questionnaire helps us understand your sexual health concerns, overall health, and lifestyle so we can prepare a personalized nutrition and wellness plan for you.

A. PERSONAL INFORMATION

1. Full Name * 2. Your age * 3. Height (cm) 4. Weight (kg) 5. Mkoa/Nchi unayoishi * 6. Namba ya Simu/WhatsApp * 7. Email 8. Hali yako ya ndoa

Nimeoa Sina mke

B. TATIZO KUU LA NGUVU ZA KIUME

9. Tatizo gani kuu unalopitia kwa sasa? *
(Chagua yote yanayokuhusu)

Kupungua hamu ya tendo la ndoa Uume kushindwa kusimama au kutokuwa imara Kuwahi kufika kileleni/kumaliza haraka Uume kushuka wakati wa tendo Kushindwa kurudia tendo la pili Kupungua hisia wakati wa tendo Tatizo lingine

10. Tatizo hili limekuwepo kwa muda gani? 11. Tatizo lilianza vipi?

Lilianza ghafla Lilianza taratibu na kuongezeka Linakuja na kuondoka

C. TATHMINI YA AFYA YA NGUVU ZA KIUME

12. Je, hamu ya tendo la ndoa imebadilikaje? 13. Uume wako husimama kwa kiwango gani? *

Unasimama kwa uimara mzuri na hudumu vizuri Unasimama lakini wakati mwingine huwa legevu Unasimama kwa udhaifu Hausimami kabisa

14. Je, uume husimama vizuri lakini hushuka haraka? 15. Kwa kawaida hufika kileleni baada ya muda gani? 16. Je, unapata maumivu wakati wa tendo au baada ya tendo?

Hapana Ndiyo, wakati wa tendo Ndiyo, baada ya tendo

Eleza sehemu na aina ya maumivu: 17. Je, unaamka asubuhi ukiwa na msisimko wa uume?

D. HISTORIA YA KUJICHUA (MASTURBATION)

18. Je, umewahi kujichua?

Ndiyo Hapana

Kama ndiyo, ulijichua kwa muda gani? Kwa wiki ulikuwa unajichua mara ngapi? Ulikuwa unajichua kwa njia gani mara nyingi?

Mkono bila kutumia kitu (mkono kavu) Mkono pamoja na sabuni/kilainishi Kwa kuangalia video au picha za ngono Kwa kulalia au kujisugua kitandani Kwa kutumia kifaa maalumu

E. AFYA YA UUME NA KORODANI

19. Una changamoto gani kwenye korodani?

Zinauma Zinavuta au zina uzito Zimesinyaa Zimevimba Kuna uvimbe au kifundo Sina tatizo

20. Je, umeona mabadiliko yoyote kwenye uume?

Umeonekana mfupi Umeonekana mwembamba Umesinyaa Hakuna mabadiliko

21. Je, unahisi ganzi au kupungua hisia kwenye uume au korodani?

F. AFYA YA MWILI KWA UJUMLA

22. Je, una shinikizo la damu (Presha)? Je, umewahi kutumia dawa za presha? Kama ndiyo, taja jina la dawa: 23. Je, una kisukari? Je, unatumia dawa za kisukari? 24. Je, una vidonda vya tumbo au tatizo la mfumo wa chakula? 25. Je, una tatizo la tezi (Thyroid)? 26. Je, una magonjwa ya moyo? 27. Je, una matatizo ya figo au ini? 28. Je, umewahi kufanyiwa upasuaji? 29. Je, kwa sasa unatumia dawa zozote za hospitali?

G. DALILI NYINGINE ZA MWILI

30. Je, unachoka sana bila sababu ya msingi? 31. Hali yako ya usingizi iko vipi?

Nachelewa sana kulala Nakosa usingizi mara kwa mara Nalala vizuri Nakoroma

32. Je, una msongo wa mawazo? 33. Je, una maumivu ya kichwa? 34. Dalili nyingine unazopata:

Kizunguzungu Moyo kwenda mbio Maumivu ya mgongo/kiuno Kufunga choo Tumbo kujaa gesi Kukojoa mara kwa mara Ngozi kuwasha

H. LISHE NA MTINDO WA MAISHA

35. Kwa kawaida unakula milo mingapi kwa siku? 36. Eleza chakula chako cha kawaida kwa siku: 37. Unakunywa maji kiasi gani kwa siku? 38. Je, unafanya mazoezi? 39. Unatumia tumbaku au sigara? 40. Unatumia pombe?

I. MAELEZO YA ZIADA YA MGONJWA

41. Eleza changamoto zako zote au taarifa yoyote muhimu ambayo ungependa tujue: 42. Unatarajia kupata msaada gani kuhusu tatizo lako?

PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT
& PERSONALIZED NUTRITION PLAN

This questionnaire helps us understand your sexual health concerns, overall health, and lifestyle so we can prepare a personalized nutrition and wellness plan for you.

A. PERSONAL INFORMATION

1. Full Name * 2. Your Age * 3. Height (cm) 4. Weight (kg) 5. Country/Region of Residence * 6. Phone Number / WhatsApp * 7. Email Address 8. Marital Status

Married Single

B. MAIN SEXUAL HEALTH CONCERN

9. What is your main concern at the moment? *
(Select all that apply)

Low sexual desire (Low libido) Difficulty getting or maintaining an erection Premature ejaculation Losing erection during intercourse Unable to perform a second round Reduced sexual sensation Other concern

10. How long have you had this problem? 11. How did the problem begin?

Started suddenly Developed gradually Comes and goes

C. SEXUAL HEALTH ASSESSMENT

12. How has your sexual desire changed? 13. How would you describe your erections? *

Firm and lasts well Firm but sometimes weak Weak erection Unable to achieve an erection

14. Do you lose your erection quickly after getting one? 15. How long does it usually take you to ejaculate?

D. SEXUAL FUNCTION & REPRODUCTIVE HEALTH

16. Do you experience pain during or after sexual intercourse?

No Yes, during intercourse Yes, after intercourse

Describe the location and type of pain: 17. Do you usually wake up with a morning erection?

E. MASTURBATION HISTORY

18. Have you ever masturbated?

Yes No

If yes, for how many years? How often did you masturbate? Which method did you use most often?

Using your hand only (dry hand) Using soap or lubricant Watching porn videos or images Rubbing against a bed or mattress Using a sex toy or device

F. PENIS & TESTICULAR HEALTH

19. Are you experiencing any problems with your testicles?

Pain Heaviness or pulling sensation Shrinkage Swelling Lump or mass No problems

20. Have you noticed any changes in your penis?

Appears shorter Appears thinner Shrinkage No changes

21. Do you experience numbness or reduced sensation in your penis or testicles?

G. GENERAL HEALTH

22. Do you have high or low blood pressure? Have you ever taken blood pressure medication? If yes, please specify the medication: 23. Do you have diabetes? Are you taking diabetes medication? 24. Do you have stomach ulcers or digestive problems? 25. Do you have a thyroid condition? 26. Do you have heart disease? 27. Do you have kidney or liver disease? 28. Have you ever had surgery? 29. Are you currently taking any prescription medications?

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About Us

Zephania Life Herbal Clinic (ZLHC) is a health-focused centre providing health education, nutritional guidance and wellness services designed to support individuals in improving their overall health and quality of life.

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Phone/WhatsApp:
+255766431675
+255656620725

Email:
khamisiibra@gmail.com
info@zephanialifeherbalclinic.co.uk

Opening Hours:

Mon – Sat:
2:00 AM – 11:00 PM

Sunday:
Closed (Special appointments only)

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PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT PERSONALIZED NUTRITION PLAN

A. PERSONAL INFORMATION

B. TATIZO KUU LA NGUVU ZA KIUME

C. TATHMINI YA AFYA YA NGUVU ZA KIUME

D. HISTORIA YA KUJICHUA (MASTURBATION)

E. AFYA YA UUME NA KORODANI

F. AFYA YA MWILI KWA UJUMLA

G. DALILI NYINGINE ZA MWILI

H. LISHE NA MTINDO WA MAISHA

I. MAELEZO YA ZIADA YA MGONJWA

PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT & PERSONALIZED NUTRITION PLAN

A. PERSONAL INFORMATION

B. MAIN SEXUAL HEALTH CONCERN

C. SEXUAL HEALTH ASSESSMENT

D. SEXUAL FUNCTION & REPRODUCTIVE HEALTH

E. MASTURBATION HISTORY

F. PENIS & TESTICULAR HEALTH

G. GENERAL HEALTH

PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT
PERSONALIZED NUTRITION PLAN

PROFESSIONAL MALE SEXUAL HEALTH ASSESSMENT
& PERSONALIZED NUTRITION PLAN