Premature ejaculation Survey

Premature Ejaculation

There are only a few steps to get started.

    Choose your Location

    What is your date of birth?

    Have you taken erectile dysfunction medicine before?

    Tell us Which erectile dysfunction medicine have you taken before?

    Do you ever have difficulties getting or maintaining an erection that is satisfying enough for sex BEFORE ejaculation?

    How often do you have a problem with this?

    Did your problem with your erection start suddenly?

    How long have you experienced a problem getting or maintaining an erection that is enough?

    What is your blood pressure reading taken within the last 6 months?

    Are you worried about having sex?

    How often do you ejaculate sooner than you or your partner want to?

    Do you Ejaculate with very little stimulation?

    Are you stressed, annoyed, or frustrated by ejaculation problems?

    How often have you had symptoms of depression or anxiety?

    Do you….?

    Do you have any of these conditions?

    Tell us if you have any physical issues with your penis that make intercourse difficult

    Write NA, if there is no physical issue.

    Tell Us if you ever had any heart problems , low blood pressure, stroke, or circulation problems where taking ED medicines can be life-threatening

    Write NA, if you don’t have any problem.

    Have you ever been diagnosed with any of the following? Select all that apply to you

    Have you ever taken or been prescribed nitrates or nitroglycerin or alpha blockers (doxazosin, prazosin or terazosin)?

    Are you allergic to any medicine?

    Please list your drug allergies and what happens when you use that drug.

    Do you take other medication(s) or have any other medical conditions?

    Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

    In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.

    Do you have any of these conditions?

    Please specify

    Anything else you would like us to know?

    Tell us about any concerns or questions you have for the medical team.

    How would you like to pay?

    upload emirates insurance details (if available)

    Billing and delivery details

    Google Map: (Please Share your Google Map Link)
    Delivery Location
    Street Name/No:
    Address Details:

    Personal Details

    First Name: Last Name:
    Mobile Number: E-mail:

    Confirm Request and Agree to Terms