Quiz – PE

Men’s Health – Premature Ejaculation
Pre-consultation Assessment

Please complete this short quiz to book in your initial consultation. It will only take 5 minutes and will help our doctors better understand your unique circumstances.

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Name
Current Address
You will receive a confirmation to this email address.
Date of Birth
What was your sex at birth?
Are you pregnant or breastfeeding?
Do you have a Medicare number or IHI?
Just to be cautious, do you suffer from any of the following?
Do you use any recreational drugs?
How often do you exercise?
Do you smoke or vape?
How many coffees or other caffeinated beverages do you drink per day?
How would you rate your average night's sleep?
How would you rate your mood recently?
A few questions about your specific condition – only a health practitioner will see this information.
How difficult is it for you to delay ejaculation?
Do you ejaculate before you want to?
Do you feel frustrated because of ejaculating before you want to?
How concerned are you that your time to ejaculation leaves your partner sexually unfulfilled?
When did this become a problem?
Do you have issues getting or maintaining an erection?
Have you ever taken or used any medications or supplements for PE before?
Are you currently taking any of the following medications?
Do you have or have you ever had any of the following?
Do you confirm that the information you have given is true and accurate, and is solely for yourself and if prescribed a medication, you will review the information supplied regarding the medication and side effects?