"(Required)" indicates required fields PREMATURE EJACULATION QUESTIONSGENERAL:1. Do you want treatment for stronger erections?(Required) Yes No 2. How often are you climaxing sooner than you would like during sex?(Required) Every time Half the time On Ocassion Rarely 3. Select your state(Required) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State 4. Tell us your date of birth(Required) MM slash DD slash YYYY ContinuePREMATURE EJACULATION QUESTIONSSPECIFIC QUESTIONS:1. How long do you typically last during sexual activity before climaxing?(Required) Before penetration < 1 minute 1-3 minutes 4-5 minutes 6-10 minutes More than 10 minutes 2. Over the past month, how was your control over ejaculation during sexual activity?(Required) Very poor Poor Fair Good Very Good 3. How distressed are you by how fast you ejaculate?(Required) Extremely Quite a bit Moderately A little bit Not at all 4. Over the past month, how satisfied were you with your sex life?(Required) Very poor Poor Fair Good Very Good Not Applicable - have not been active with a partner in the past month 5. To. What extent does how fast you ejaculate cause difficulty in your relationship(s)?(Required) Extremely Quite a bit Moderately A little bit Not at all Not Applicable - do not currently have a partner 6. Have you always experienced early ejaculation during all or almost all sexuality?(Required) Yes No 7. Have you taken medication or used other types of treatment to delay ejaculation?(Required) Yes No (This includes medications prescribed, behavioral modifications, supplements or medications purchased over the counter or online or other treatments.)8. Do you have difficulty getting or staying hard before ejaculating during sexual activity?(Required) No Rarely Sometimes Often or always 9. Select the option that best describes your typical erection with a sexual partner(Required)Penis does not enlargePenis is larger, but not hardPenis is hard, but not hard enough for penetrationPenis is hard enough for penetration, but not completely hardPenis is completely hard and fully rigid10. Do you have low sex drive, a general lack of energy, or a noticeable decrease in physical strength or endurance?(Required) No Yes 11. What is your gender?(Required) Man Woman Transgender Man Transgender Woman Genderqueer / Non-binary Agender Questioning Different Identity (We ask this question of all of our patients to ensure that we provide you with safe and effective care. We are inclusive of all people.)12. What was your sex assigned at birth?(Required) Male Female (For example, on your original birth certificate)13. Do you experience any of the following cardiovascular symptoms?(Required)Chest pain when climbing 2 flights of stairs or walking 4 blocksChest pain with sexual activityUnexplained fainting or dizzinessAbnormal heart beats or rhythmsNone of these apply to me14. Have you smoked, ingested, or used any of the following within the past 3 months?(Required) Poppers or Rush (Amyl Nitrate or Butyl Nitrate) Cocaine Methamphetamine (Crystal Meth) Ecstasy, Molly, or MDMA Cigarettes Cannabis Other No I don’t use any of these 15. 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?(Required) Yes No 16. Do you have or have you been previously diagnosed with any of the following?(Required) Stroke, mini stroke, or TIA Diabeties Mental health or psychiatric conditions Prostate conditions Kidney diseases or conditions Liver, stomach, or other gastrointestinal conditions Nerve, spinal cord, or brain disorders Heart conditions or diseases Vascular conditions affecting arteries or veins Penis conditions other than ED Low blood pressure High blood pressure HIV / AIDS Other chronic medical conditions None of these apply to me ContinueName(Required) First Last Email(Required) Password(Required) Enter Password Confirm Password
