Premature Ejaculation questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. What treatment are you looking for? *

EMLA cream
Priligy 30mg 3 tablets
Priligy 30mg 6 tablets
Priligy 60mg 3 tablets
Priligy 60mg 6 tablets

2. How difficult is it for you to delay ejaculation? *

Not difficult at all
Somewhat difficult
Moderately difficult
Very difficult
Extremely difficult

3. Do you ejaculate before you want to? *

Almost never or never 0%
Less than half the time 25%
About half the time 50%
More than half the time 75%
Almost always or always 100%

4. Do you ejaculate with very little stimulation? *

Almost never or never 0%
Less than half the time 25%
About half the time 50%
More than half the time 75%
Almost always or always 100%

5. Do you feel frustrated because of ejaculating before you want to? *

Not at all
Slightly
Moderately
Very
Extremely

6. How concerned are you that your time to ejaculate leaves your partner sexually unfulfilled? *

Not at all
Slightly
Moderately
Very
Extremely

7. Have you used premature ejaculation treatment before? *

Please provide more details *

8. Do you have issues producing or maintaining an erection? *

The symptoms of premature ejaculation can be improved by using erectile dysfunction treatment.

9. Do you currently have a heart condition or have previously had one? *

Please provide more information *

10. Are you currently experiencing low blood pressure or have a past history with dizziness when you stand up or lie down or fainting? *

Please provide more information *

11. Are you currently or have you previously suffered with severe depression (including hospital treatment/multiple medications) bipolar disorder or mania? *

Please provide more details *

12. Are migraines or severe headaches something you have ever suffered with? *

Please provide more details *

13. Do you currently have epilepsy or have any history of a severe head injury or seizures? *

Please provide more details *

14. Do you currently have, or have ever had a liver or kidney condition? *

Please provide more details *

15. Do you currently have any eye conditions, for example Glaucoma? *

Please provide more details *

16. Do you currently have an issue with your prostate such as conditions prostatitis or benign prostate hypertrophy? *

Please provide more details *

17. Do you currently take any medications for blood clotting disorders or medication which affects your blood clotting? *

Please provide more details *

18. Do you currently use recreational drugs? *

Please provide details *

19. Aside from what has already been shared, do you have any significant medical illness, conditions, stays in hospital or past surgical procedures? *

Please provide details *

20. Do you currently take any prescription medication, over the counter medication, recreational drugs that we have already asked you about? *

Please tell us more about this *

21. Do you have any allergies? *

Please give us more information *

22. Please confirm you have understood the explanation of our premature ejaculation treatment. *

Please confirm that you understand that you may need to take the treatment up to 4 times before any benefits are shown

23. Is there anything else you would like to share with us? *

Share additional details below *

Checkboxes *

Can you confirm that you have understood all the questions asked, and answered them honestly. This treatment is only for your own self use. You also understand the side effects, other options available.

Price *

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Premature Ejaculation