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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? *
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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. *

More Services

The sections below provide further details on available services and associated fees. All treatments are subject to clinical assessment and suitability.

Home Visit
Within 20 miles of Coventry (09:00–22:00): £279

Patients requesting a home visit are required to book an initial telephone consultation (£45). If the home visit proceeds following this assessment, the £45 fee will be deducted from the home visit cost.

  • Injection volume under 2 ml: £250

  • Injection volume over 5 ml: £300

Simple Skin Lesions
Skin tags, seborrhoeic warts, simple moles, lipomas under 1 cm:
£250 per lesion

Large or Cystic Lesions
Epidermoid, pilar, sebaceous, or ganglion cysts, large lipomas:
£350 per lesion

Additional Lesions

  • Additional skin lesion: £50

  • Additional cystic lesion: £100

Ingrown Toenail Surgery
£379 per toe

Histology
All pigmented lesions must be sent for histology or at clinical discretion or patient preference:
£100 per sample

Blood tests, allergy testing, STI screening, cultures, swabs, and imaging referrals are available where clinically appropriate.

Prices depend on the tests required and will be discussed following telephone, video, or face-to-face assessment.

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