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Premature Ejaculation Questionnaire
Step 1 of 6
16%
Please select the answer that best represented your response for each of the questions below. While your experiences may change from time to time, please report your general experiences with intercourse. (Ejaculation here refers to release of semen after your penis enters your partner).
How difficult is it for you to delay ejaculation?
*
Not difficult
Somewhat Difficult
Moderately difficult
Very difficult
Extremely difficult
Do you ejaculate before you wish?
*
Almost never/never
Less than half the time
About half the time
More than half the time
Almost always/always
Do you ejaculate with very little stimulation?
*
Almost never/never
Less than half the time
About half the time
More than half the time
Almost always/always
Do you feel frustrated because of ejaculating before you want to?
*
Not at all
Slightly
Moderately
Very
Extremely
How concerned are you that your time to ejaculation leaves your partner sexually unfulfilled?
*
Not at all
Slightly
Moderately
Very
Extremely
Please advise how you would like to receive your confidential results
Name
*
Phone
*
Email
*
Preferred confidential method of receipt
*
Email
SMS
Phone
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