ED Form

Premature Ejaculation Disorder (PE) Questionnaire

Thank you for taking the time to answer these questions. Based on your answers, you may be eligible to have Extenza shipped directly to your door!
Name*

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Please provide your email address*
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Please provide your date of birth*

MonthDayYear
Date
What was your sex assigned at birth?*

MaleFemale
Sometimes sexual complications can result from lowered testosterone, please check the box next to any of the below symptoms that you may have:*

FatigueLack of EnduranceDepressionMental FogDecreased MotivationLoss of Muscle MassNone of the above
Have you always had premature ejaculation disorder?*

YesNoNot sure
How often do you have difficulty getting or maintaining an erection?*

OftenOccasionallyRarelyNever
How fast do you ejaculate?*

Before penetrationLess than 30 seconds after penetrationMore than 30 seconds after penetrationMore than a minuteA couple or more minutes
Do your symptoms cause you to avoid sex?*

OftenOccasionallyRarelyNever
Do you feel frustrated because you ejaculate before you want to?*

Not at allSlightlyModeratelyVeryExtremely
Check all that apply. Have you ever had any of the following conditions:*

Depression or Anxiety that required treatment by a healthcare professionalBipolar DisorderSchizophrenizBorderline Personality DisorderHistory or suicidal thoughts or plans to hurt yourselfSeizuresNone of the above apply to me
Check all that apply. Do you currently have, or have you ever had experience with the following:*

HIVHeart attack, heart failure, narrowing of the artieres.Severe blood pressure or blood pressure that changes widely."Hypertrophic cardiomyopathy" (abnormal thickening of the heart wall)."QT Prolongation" (specific change to the electromagnetic signals that make your heart beat).A family history of QT ProlongationClotting or bleeding disorderStroke or bleeding from your brainA blood cell disorder, such as sickle cell disease, myeloma, lymphoma, or leukemiaA rare genetic disorder called "retinitis pigmentosa", which typically causes gradual changes to your visonA sudden loss of vision caused by loss of blood flow to you eye (called "anterior ischemic optic neuropathy)A rare disorder called "pulmoary hypertension", which specifically affects blood vessels that supply the lungs (this is NOT the same as at the common diagnosis of high blood pressure)For health reasons, or any other reasons, have you been advised to not have sexNone of the above apply to me
Check all that apply. Do you have any of these conditions:*

A marked curve or bend in the penis that interferes with sex "Peyronie's Disease"Pain with erections or ejaculationA foreskin that is too tightFibrous tissue in the penis (lumps and bumps under the skin that feel hardNone of the above apply to me
Check all that apply. Do you currently have, or have you ever experienced any of the following:*

Surgery or radiation to the prostate or pelvisKidney transplant or any condition affecting the kidneysLiver DiseaseMultiple Sclerosis (MS) or similar disease, spinal injury or paralysis or neurological diseaseStomach, intestine, or bowl ulcersHeart arrhythmias, which is abnormal beating of the heartAny acquired, congenital, or developmental abnormalities of the heart including heart murmursNone of the above apply to me
Check all that apply. Do you have any of the following symptoms related to the heart or blood vessels:*

Abnormal heart beats, too fast or too slowPain in your chest of trouble breathing that gets worse with physical activity, such as walking up 2 flights of stairsUnexplained episodes of fainting, lightheadedness, or dizzinessCramping or pain the calves or thighs with exercise (claudication)None of the above apply to me
Check all that apply. Do you currently use, or have an active prescription for any of the following:*

Medication to treat any psychiatric condition or mood disorder, including anxiety or depressionAbsolutely any medicine including nitratesAny ALPHA blocker, which is not the same as beta blocker. Examples of ALPHA blockers include Flomax (tamsulosin), Cardura (doxazosin), and Minipress (prazosin)Nitroglycerin in any form - tablet, spray, patch, or ointmentSupplements that boost nitric oxideMonoket (isosorbide mononitrate, Bidil, or Isordil (isosorbide dinitrate), which are commonly prescribed to prevent chest pain associated with heart diseaseAdempas (riociguat)Regular or daily use of NSAIDs (Advil, Aleve, Ibuprofen), or blood thinnersNone of the above apply to me
Do you currently have, or have you ever experienced, any of the following:*

Low sodium levels in your blood of SIADHClosed angle glaucomaIncreased intraocular pressure (pressure in the eyes) measured by a healthcare providerMethemoglobinemiaHistory of serotonin syndromeNo, I have never had any of these conditions
Check all that apply. Have you used any of the following recreational drugs in the past 6 months:*

Methamphetamines or amphetamines (crystal meth)Poppers or RushAmyl Nitrate, Butyl NitrateCocaineMolly, MDMA, EcstasyOtherNone of these apply to me
Please list any allergies to prescription or over-the-counter medications, herbs, vitamins, supplements, food, dyes, or anything else. List N/A if none. *
Please list any medical conditions or surgeries you have had, that were not listed above. List N/A if none.*
Please list any medications previously taken for Erectile Dysfunction, or N/A for none:*
Please list the dosage of any Premature Ejaculation or Erectile Dysfunction medications previously taken, or N/A for none:*

Extenza™*

Extenza™ (Tadalafil and Tramadol HCL)minimum order is 4 doses

$6.50

Dosage Size	Quantity	Price
20/30 mg		$6.50

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Premature Ejaculation Disorder (PE) Questionnaire

After you submit your order, schedule a convenient time for your live online doctor consultation on the next page.