Rxpress

premature ejaculation

Premature ejaculation is when a man ejaculates earlier than they’d like to during sex – usually within two minutes of having sex. It is a common condition that affects up to one in 3 men, and has a number of physical and psychological causes. If you need help lasting longer in the bedroom rxpress offers effective treatments that can help you get your sex life back under control.

Fill in the form below and one of our clinicians will be in touch today with details on how we can help

Premature Ejaculation Consultation Form

Full name:

Date of Birth (DD/MM/YYYY):

Age:

Home Address:

Email:

Telephone:

NHS number (optional):

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

Do you have any allergies?
YesNo

If yes, please provide details:

Do you have any significant past or present medical conditions?
YesNo

If yes, please provide details:

Are you currently taking any medication?
YesNo

If yes, please list all your current prescription medication including any over-the-counter medication:

Are you allergic or intolerant to any medication?
YesNo

If yes, please specify:

Do you suffer from depression or other mental health conditions?
YesNo

If yes, please specify:

Do you experience erection problems?
YesNo

How long have you experienced premature ejaculation?

Is ejaculation occurring before or shortly after penetration, and is it causing distress?
YesNo

Do you have any issues with your prostate or urinary system?
YesNo

If yes, please provide details:

Are you experiencing any pain or discomfort during sex?
YesNo

If yes, please specify:

Have you tried any treatment for premature ejaculation before?
YesNo

If yes, please specify:

Are you in a stable relationship or sexually active?
YesNo