Premature Ejaculation assessment | Pharma Aesthetics

Skip to content

Search

Account

£119.00 1 Basket

Main Menu

Online GP
Online Pharmacy
NMN Supplements
Aesthetic Treatments
Walk In Services
Online Doctor
Weight Loss Clinic

£119.00 1 Basket

Search

Main Menu

Online GP
Online Pharmacy
NMN Supplements
Aesthetic Treatments
Walk In Services
Online Doctor
Weight Loss Clinic

Online Doctor now available

Premature Ejaculation Treatment Medical Questionnaire

"*" indicates required fields

Step 1 of 8

12%

Ordered Before?

Please sign in and re-order. To ensure no delays to your order, we must have a medical questionnaire filled. Log In
You can order again by selecting the product from your dashboard, clicking Order Again.

Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Premature Ejaculation Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Do you frequently ejaculate sooner during sexual intercourse than you or your partner would like?*

Yes

No

Please provide more information below.*

Is this early ejaculation uncontrollable, happening before or shortly after penetration?*

Yes

No

Please provide more information below.*

Have you experienced significant stress or anxiety due to this condition?*

Yes

No

Please provide more information below.*

Has this issue been persistent or recurrent for more than six months?*

Yes

No

Please provide more information below.*

Do these premature ejaculation episodes occur in the majority of sexual encounters?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medications that could potentially affect your sexual function, such as antidepressants or blood pressure medications?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you been diagnosed with any neurological disorders or hormonal imbalances that might contribute to premature ejaculation?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any chronic health conditions, like diabetes or heart disease, that could be impacting your sexual health?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously sought treatment for premature ejaculation, and if so, what types of treatments were attempted?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you experiencing any other sexual dysfunction issues, such as erectile dysfunction, that could be related to or affecting your condition?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions are designed to ensure a comprehensive understanding of the patient's condition and any underlying health issues, which is crucial for prescribing the most appropriate and effective treatment for premature ejaculation.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Name

This field is for validation purposes and should be left unchanged.

Ordered Before?

Sign In And Reorder Prescription

16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

Facebook Instagram

£119.00 1 Basket

Pharmacy

Online Doctor
Online Pharmacy

Aesthetics

Dermal Filler Treatment
Fine Line & Age Wrinkles
Vitamin B12 Injection
aqualyx fat dissolving injection
lipo cavitation treatment

About

Cart
Checkout
Returns Policy
My Account
Delivery
Feedback and Complaints
About us
Privacy Policy
Terms and Conditions
Contact us

Pharma Aesthetics Ltd © All rights reserved

Powered by Elliot Web Designs

Shopping Basket