Myonlinedoctor Erectile dysfunction treatment Registration Page

In order to prescribe treatments for Premature ejaculation our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

I confirm that I suffer from PE and cannot control when I ejaculate.

Yes No

How long have you been sexually active?

How long have you been suffering from premature ejaculation?

Less than 1 year more than 1 year

How often do you experience PE?

Do you ejaculate quickly when masturbating?

Yes No

Can you manage to penetrate and or maintain an erection beyond two minutes without ejaculating?

Yes No

Does your PE affect the relationship you are in?

Yes No

Please provide details of how it has affected your relationship.

Does that cause you distress?

Yes No

What treatments, if any, have you tried for PE in the past?

Do you suffer from any prostate problems such as infection or enlargement?

Yes No

Are you taking any antidepressants?

Yes No

Do you suffer from panic attacks and/or do you ever experience suicidal throughts?

Yes No

Do you suffer from bipolar disease, mania or seizures?

Yes No

Do you suffer from kidney (renal) or liver (hepatic) disease?

Yes No

Do you have any heart problems, particularly affecting the heart rhythm or palpitations?

Yes No

Do you faint easily or do you feel dizzy when standing up too quickly after lying down?

Yes No

I understand Priligy and ED medicines (Viagra, Cialis and Levitra) must not be taken at the same time as this could cause low blood pressure and fainting. To avoid these side effects I understand I must leave at least 2 weeks between taking Priligy and taking Viagra, Levitra or Cialis.

Have you been diagnosed with low blood pressure or postural hypotension?

Yes No

Do you drive Heavy Goods Vehicles or use heavy machinery?

Yes No

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