Premature Ejaculation

How often are you climaxing sooner than you would like during sex?

What performance results are you looking for?

Which option best describes the typical duration of time before you climax during sexual activity?

Over the past month, how was your control over ejaculation during sexual activity?

How distressed are you by how fast you ejaculate?

How satisfied are you with your sex life over the past month?

To what extent does how fast you ejaculate cause difficulty in your relationship(s)?

Have you experienced fast ejaculation during all or almost all sexual activity since you became sexually active?

Have you ever been treated with medication for this? If yes, what was your treatment and was it successful?

Have you tried any of these medications? Select all that apply.

If you took any past treatments, did you have difficulty achieving or maintaining your erection until you ejaculate during sexual activity?

If you took any past treatments, did you experience any bothersome side effects?

If yes, what were your side effects?

Do you experience any of the following cardiovascular symptoms? Please select all that apply.

Have any of your first degree relatives (parents or full siblings) ever attempted suicide or been diagnosed with bipolar disorder, hypomania, mania, or major depression?

What was your last blood pressure reading? You can find this information from a recent medical visit or by taking your blood pressure at a local pharmacy or grocery store. If you're not sure, you can leave this blank.

Do you have or have you previously been diagnosed with any of the following? Please select all that apply.

Is there anything else related to treatment that you'd like to ask or discuss with your medical provider?

Do you have a preferred treatment?

Would you like to share anything else with your provider through an upload?

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