Questionnaire premature ejaculation

What is your biological gender?

The doctor needs this information to ensure that the treatment is medically appropriate for you.

General health and lifestyle

Are you able to walk or climb stairs for 3-5 minutes without becoming breathless or feeling a pain in your chest?

What is your height and weight?

Do you smoke?

Sexual health

How quickly do you ejaculate after penetrating your partner?

How long have you been having premature ejaculations?

Do you sometimes have problems getting an erection or maintaining it for longer?

Do you have pain when you ejaculate or urinate?

Current medications and health status

Have you tried other treatments/medications for premature ejaculation?

Have you ever been diagnosed with low blood pressure (below 90/60)?

Are you taking any of the following medications?

  • Antidepressants
  • Thioridazine
  • Tryptophan
  • Linezolid
  • Tramadol
  • Migraine medication
  • HIV medications such as amprenavir and fosamprenavir

Are you allergic to any substances, medications, ingredients or foods?

Do you have any of the following illnesses or allergies?

Are there any other health or medical details that might be important to the doctor?

If any of the following applies to you, we would like to hear from you.

I have one or more medical conditions

I have had surgery before

I am taking medication(s)

I have one or more allergies

I have one or more close relatives with a medical condition

I use recreational drugs

Legally effective consent

I understand and confirm that:

  • I will read the full leaflet before taking the medicine.
  • I am over 18 years old and the medicine is for my personal use only.
  • I answered all questions truthfully to the best of my knowledge and belief.
  • Doctors accept my answers and the prescriptions issued are based on my answers. False information can therefore be harmful to your health. I take full responsibility for this.
  • I will inform my doctor about this purchase/prescription at my next visit so that my doctor can continue to monitor my health.
  • I hereby confirm that I have understood the possible side effects of the treatment and have also informed myself about its effectiveness and alternative treatment options.

I agree to the Terms and Conditions and Privacy Policy of Directdoc and – if I choose delivery of the prescribed medication through a partner pharmacy – to the Terms and Conditions and Privacy Policy of the partner pharmacy delivering my order.

I agree to the Terms and Conditions and Privacy Policy of Directdoc and – if I choose to have the prescribed medications delivered through a partner pharmacy – to the Terms and Conditions and Privacy Policy of the partner pharmacy delivering my order. In such a case, I also consent to the partner pharmacy accessing my health data processed through this site to fulfill a prescription and provide pharmaceutical advice. Furthermore, I agree to the transfer of my health data to the cooperating physician treating me and release this physician from their duty of confidentiality to the extent necessary for the execution of my treatment and the delivery of medications. I acknowledge that I have the option to have a prescribed medication delivered by a partner pharmacy of directdoc.eu or to receive the issued prescription by mail. Finally, I agree that non-medical personnel may access my health data to respond to my customer support inquiries. With regard to the transfer of data to customer support, I also release the physician from their duty of confidentiality. I can revoke my consent at any time for the future. I acknowledge that consent is necessary for both treatment and the delivery of prescribed medications. I also agree that directdoc.eu may immediately begin arranging telemedicine services and that the cooperating physician facilitated by directdoc.eu may commence telemedicine services immediately. I acknowledge that my rights to withdraw this consent prematurely expire if the mediation and telemedicine services have been fully provided.

You are entitled to a telephone call from the pharmacy team to discuss your treatment if you are using it for the first time.

Make your choice:

Can we share information about your treatment with other healthcare professionals?

To help us and other healthcare providers treat you safely, we want to share information about your treatment with us through the LSP (National Switching Point ). This is a secure and accessible platform for other doctors and pharmacists.