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Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

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Doctor-Led Premature Ejaculation (PE) Medical Questionnaire

Doctor-Led Premature Ejaculation (PE) Medical Questionnaire

Confidential • Non-judgemental • Evidence based

Important: Premature ejaculation can sometimes be linked to treatable medical or psychological conditions.
This questionnaire allows our clinicians to assess whether treatment is appropriate and safe for you.

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Step 1 of 10


SECTION 1 — About You

Important: Premature ejaculation can sometimes be linked to treatable medical or psychological conditions. This questionnaire allows our clinicians to assess whether treatment is appropriate and safe for you.
1. Are you completing this assessment for yourself? *
2. Sex at birth: *
3. Age (you must be 18–64 years): *

5. GP details (recommended for safety and continuity):

SECTION 2 — Your Main Concern

6. Over the past 6 months, in most sexual encounters, do you ejaculate sooner than you or your partner would like? *
7. Which best describes your experience? *
8. How often does this affect you? *
9. How long has this been an issue? *
10. Approximately how long does it usually take before ejaculation occurs during sexual activity? *
11. Do you also have difficulty getting or maintaining an erection sufficient for sexual activity? *
12. Does ejaculating sooner than you would like cause personal distress or relationship difficulty? *

SECTION 3 — Symptoms Requiring Medical Review

12. Do you experience pain or discomfort when ejaculating or passing urine? *
13. Have you ever had:
If yes to any of the above, a doctor consultation may be recommended.

SECTION 4 — Medical History

14. Have you ever been diagnosed with any of the following? (tick all that apply)
Mental Health Cardiovascular Neurological Urological / Endocrine Other

SECTION 5 — Blood Pressure & Circulation

15. Have you been told you have:
16. Do you know your most recent blood pressure reading? *
/

SECTION 6 — Medication & Safety Checks

17. Are you currently taking any medication or substances? *
18. Are you taking any antidepressants, including SSRIs or SNRIs? *
19. Are you taking any medicines that affect blood pressure, heart rhythm or bleeding? *
20. Do you take medicines for erectile dysfunction (e.g. sildenafil, tadalafil)? *
21. Do you use recreational drugs (including cocaine or cannabis)? *
22. Do you have any known drug allergies or sensitivities? *

SECTION 7 — Lifestyle Factors

23. Smoking: *
24. Alcohol intake: *

SECTION 8 — Previous Treatment

26. Have you previously tried treatment for premature ejaculation? *

SECTION 9 — Understanding & Consent

Please confirm the following:

SECTION 10 — Consent for Remote Assessment

28. I consent to assessment via an online medical consultation and understand a doctor may request further information or recommend a live consultation if required for safety. *
Common Questions

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