Chinese Fertility Herbs

FertilityFormulas.com
Men's Fertility Health Form

Fertility Formulas
Patricia Karnowski M.S.O.M.
P.O. Box 1152
Pinehurst, NC 28370
910-420-2194

Your Traditional Chinese Medical Diagnosis

To create a custom herbal formula we need to diagnose your condition based on the theories of Traditional Chinese Medicine.

Please complete this health history form. It will be review and you will be called by Fertility Herbalist, Patricia Karnowski M.S.O.M. to discuss your Chinese herbal formulas options.


Please complete the form below . This is a secure website and your information will not be shared.

Men's Health Form
Full Name:
Age:
How long have you had problem:
 Decreased sexual energy
 undescended testes
 urological surgery
 varicocele
 difficulty getting an erection
 difficulty holding an erection
 Poor sperm morphology
 low sperm motility
 Low sperm count
 urinary difficulties
 smoke marijuana
 smoke cigarettes
 poor diet
 stressful life
 low back pain or weakness
 dizziness
 diarrhea or loose stools
 constipation
 low energy
 cold hands and feet
 warmer than people around you
 colder than people around you
 physically stressful job
comments:
Phone number:
Best times to call:
You will be called by the herbalist to go over this information.
Time Zone:
email address:

We Protect Your Privacy and Never Share this Information.



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