Describe your family life during childhood
Did you have any special family or friend during your childhood?
Did you receive sexual information at home or maybe at school?
How old were you when you experienced your first ejaculation?
How old were you when you first masturbated?
How would you describe the sexual problem you are experimenting? – I ejaculate before I´d like to.
How would you describe the sexual problem you are experimenting? – I ejaculate before penetration
How would you describe the sexual problem you are experimenting? – I ejaculate just a few minutes after penetration
How would you describe the sexual problem you are experimenting? – I ejaculate without control only sometimes
How would you describe the sexual problem you are experimenting? – I always ejaculate without control
How long have you been suffering this problem for?
Are you currently suffering from any illness for which you are being treated?
Are you currently taking any medication? (If yes which one?)
Have you ever undergone a surgical procedure? Please, specify
Have you ever visited a psychologist / psychiatrist? If yes, please specify
Do you think that you are under a high level of family / work / financial stress?
Do you fall in love easily?
Do you have trouble sleeping?
Do you have frequent dreams?
Do you have erotic dreams?
Do you have nocturnal ejaculations?
Have you ever had a sexually transmitted disease?
Have you been HIV tested?
Are you in a stable relationship at the moment?
If afirmative since when? (mark 0 if negative)
How would you describe the quality of your relationship with your partner? (Regardless of you sexual problem)
How frequently do have sexual intercourse with your partner?
Who initiates the sexual activity? Does your partner maintain an active role or a passive role?
Do you have sexual intercourse with anyone besides your partner?
How would you describe your opinion of women?
Do you have many friends or do you prefer being alone?
If you are heterosexual. Have you experienced or currently are experiencing any homosexual relationships?
How would you describe your first sexual encounters?
Did your first sexual encounters occur with prostitutes?
Do you think you ejaculate too quickly?
Does your partner have the same opinion?
Since when do you suffer from premature ejaculation?
Do you ejaculate rapidly in all sexual encounters? (Percentage %)
Do you ejaculate before penetrating the vagina?
Do you ejaculate when you try to penetrate the vagina?
Does ejaculation occur after a few pelvic thrusts? (Back and forth movements)
Could you determine after how many minutes/seconds?
Are you able to control the ejaculation with a particular person?
Can you control the erection in particular places?
How would you describe the quality of foreplay before intercourse?
If you masturbate, how often do you do it?
During masturbation, are you able to maintain a high level of arousal whilst preventing ejaculation for a long time?
How would you describe the quality of your erection?
Do have trouble maintaining the erection?
Have you experienced a loss of erectile quality since the premature ejaculation appeared?
During the arousal stage, can you detect the moment at which ejaculation approaches?
Are you able to hold back arousal without ejaculating?
Do you take drugs / alcohol in order to hold the ejaculation longer?
Do you masturbate before intercourse in order to delay ejaculation during sex?
Does you partner avoid sexual having sex with you?
What is your partne´s opinion and how would you describe his/her reaction?
Are you able to make your partner have orgasms
If afirmative. Through coital intercourse or through other means of stimulation?
What kind of contraceptive method do you use?
Do you feel pleasure when you have orgasms?
After the first premature ejaculation do you attempt a second one?
How do your feel after you ejaculate prematurely? How do you thing this affects you?
Thank you for taking our survey.
« Back Next »