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Premature-Ejaculation

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What is your date of birth?
What is your height?
Height?
What is your weight?
Weight?
What is your blood pressure?
Do you have any allergies? Yes No
Do you smoke, drink alcohol or take any recreational drugs? Yes No
Do you take herbal, homeopathic or ayurveda medicine? Yes No
What diagnosis/treatment do you require medicine for and what medicine has your doctor recommended in the past?
Have you seen your Doctor about the present condition? Yes No
Have you taken this medicine before with a prescription in less than 6 months ? Yes No
Have you had your blood pressure checked in the last 12 months? Yes No
Do you currently take any other medication (prescribed or bought over the counter)? Yes No
Do you usually ejaculate before you want to? Yes No
How long after penetration do you ejaculate? (e.g 2 minutes, 5 minutes, 10 minutes)
Have you been diagnosed with premature ejaculation by a doctor? Yes No
How long have you been suffering from premature ejaculation? (Write details in months e.g. 3 months, 5 months, )
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Would you give us permission to contact your GP if we need to discuss your treatment and to keep them informed about any medication we may prescribe to you? yes no
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