Please enable JavaScript in your browser to complete this form.Name *FirstLastAge *Sex *Marital status and duration *Mobile Number *Email * 1. In the past 6 months, when you had sexual intercourse, how often did you have control over when you ejaculated (released semen during sex)?no sexual intercourse or tried to avoid sexual intercoursealmost always or alwaysabout half of the timeless than half of the times or sometimesalmost never or never2. Over the past 6 months, during sexual intercourse, how much confidence did you have over when you ejaculated (released semen during sex)?no sexual intercourse or tried to avoid sexual intercoursehigh confidenceneither high or low confidence (neutral)moderately low confidencevery low confidence3. Over the past 6 months, how often was sexual intercourse satisfactory for you?no sexual intercourse or tried to avoid sexual intercoursealmost always or alwaysabout half of the timeless than half of the timesalmost never or never4. Over the past 6 months, during sex how satisfied were you with your sense of control over when you ejaculated without any medicine?no sexual intercourse or tried to avoid sexual intercoursevery satisfiedsomewhat satisfiedNeither satisfied or dissatisfied nor didn’t try to control very dissatisfied5. Over the past 6 months, during sexual intercourse, how satisfied were you with your timing of sex before ejaculation?no sexual intercourse or tried to avoid sexual intercoursevery satisfiedneither satisfied nor dissatisfieddissatisfiedvery dissatisfied6. Over the past 6 months, how satisfied have you been with your sex life overall?no sexual intercourse or tried to avoid sexual intercoursevery satisfiedneither satisfied nor dissatisfieddissatisfiedvery dissatisfied7. Over the past 6 months, how satisfied you have been with your sexual relationship with your partner?no sexual intercourse or tried to avoid sexual intercoursevery satisfiedsomewhat satisfiedsomewhat dissatisfiedvery dissatisfied8. Over the past 6 months, how much pleasure has sexual intercourse given to you?no sexual intercourse or tried to avoid sexual intercoursehigh pleasuremoderate pleasurelow pleasurevery low pleasure or no pleasure at all9. Over the past 6 months, how much you were distressed (frustrated) thinking about the duration of your sexual intercourse before you ejaculate?no sexual intercourse or tried to avoid sexual intercourseextremely distressed or think about it whole daymoderately distressed or think about it during sexslightly distressed or think about it later sometimes not at all distressed10. Over the past 6 months, have you experienced that your problem is getting worse and you are now having other sexual problems?no sexual intercourse or tried to avoid sexual intercourseGetting worse + erection (hardness in penis) problemGetting worse + low libido (having less interest in having sex)Both of the above Not getting worse (same since beginning)Describe your problem below EmailSubmit
