EJACULATORY DYSFUNCTION
Version 06.08.23
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
1. What type of ejaculatory dysfunction are you experiencing? (check all that apply)
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Premature ejaculation
Anejaculation (absence of ejaculation with orgasm)
Painful ejaculation
Only answer 2-5 if selected pre-mature
2. When experiencing premature ejaculation has this problem been:
Lifelong – (consistent from beginning of sexual interactions)
Acquired – (new issue after period of having satisfactory ejaculation latency)
3. What forms of sex do you have the issue of premature ejaculation? (Select all that apply)
Oral
Vaginal
Anal
Other
4. How much time elapses from penile penetration until ejaculation on average?
Less than 1 minute
1-3 minutes
3-7 minutes
7-20 minutes
>20 minutes
5. For how many years has premature ejaculation been causing distress?
Patient or Representative Signature
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Date
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