PE Online Visit - Questions

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As part of your online health consultation you must provide the below information
Name*
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Section A- PREMATURE EJACULATION
Step #1 – Answer a few questions to see if you qualify for online ordering
Question 1 of 10
Can you achieve and maintain 100% full erections until ejaculation?
- Yes
- No

Question 2 of 10
How long have you experienced PE?
- Life Long
- Recent

Question 2.1 of 10
How long does it take, on average, to ejaculate after penetration?

Question 2.2 of 10
Is it getting worse recently?
- Yes
- No

Question 2.1 of 10
How recent?

Question 2.2 of 10
Is the strength of your erections weakened?
- Yes
- No

Question 3 of 10
Please elaborate on your experience

Question 4 of 10
What, in your opinion has caused this problem?

Question 5 of 10
What treatments have you tried? Indicate the success and adverse effects, if any

Question 6 of 10
What do you wish to achieve from this consultation?

Question 7 of 10
When masturbating, indicate the strength of your erection from 1-10 (10 being strongest rigidity).

Question 8 of 10
Please list medications you are using on a regular basis?

Question 9 of 10
Are you taking any SSRIs (such as Prozac, Zoloft, Paxil, Lexapro, Celexa, Luvox)?
- Yes
- No
NOTE: SSRI SHOULD NOT BE TAKEN TOGETHER WITH IMPEREX AND IMPEREX PLUS

If you do, please indicate which one:

Question 10 of 10
Have you had a physical exam with a healthcare provider in the past 12 months? If so, did the provider examine the genitals (penis, testes)? If not, we recommend visiting a healthcare provider as soon as you can.
- Yes, it was normal
- Yes, but there was issues. Please elaborate
- No. Please elaborate

Elaborate

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Section B- SEXUAL HEALTH INVENTORY FOR MEN (SHIM)
Your answer indicates a possible Erectile Dysfunction issue that could be contributing to your PE issue. Would you like information on ED first?

We're now going to take you through the SHIM Questionnaire

Purpose of SHIM

The SHIM Questionnaire (also known as the IIEF-5) is an abridged and slightly modified 5-item version of the 15-item International Index of Erectile Function (IIEF), designed for easy use, by clinicians, to diagnose the presence and severity of ED in clinical settings.

This diagnostic tool may reduce the number of incorrectly diagnosed or underdiagnosed cases. It is intended to complement the physical examination and patient history as a means to detect ED.

Question 1 of 5
Over the past 6 months:
How do you rate your confidence that you could keep an erection?
- Very low
- Low
- Moderate
- High
- Very High

Question 2 of 5
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
- Amost never or never
- A few times(much less than half the time)
- Sometimes(about half the time)
- Most times(much more than half the time)
- Almost always or always

Question 3 of 5
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
- Almost never or never
- A few times(much less than half the time)
- Sometimes(about half the time)
- Most times(much more than half the time)
- Almost always or always

Question 4 of 5
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
- Extremely difficult
- Very difficult
- Difficult
- Slightly difficult
- Not difficult

Question 5 of 5
When you attempted sexual intercourse, how often was it satisfactory for you?
- Almost never or never
- A few times(much less than half the time)
- Sometimes(about half the time)
- Most times(much more than half the time)
- Almost always or always

Score
SHIM SCORE CHART, followed with explanation

Interpretation of score:
- 22-25 - No ED.
- 17-21 - Mild ED
- 12-16 - Mild-to-Moderate ED
- 8-11 - Moderate ED
- 5-7 - Severe ED

No ED indicated - Proceed back to PE medication solution

Schedule Consultation

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Section C – ERECTILE DYSFUNCTION- Sexual History
Question 1 of 10
Do you have problems achieving or maintaining an erection, or both?
- Yes
- No

Question 2 of 10
Did it start suddenly or gradually?
- Suddenly
- Gradually

Question 3 of 10
Has it been getting worse?
- Yes
- No

Question 4 of 10
Do you have problems with one partner but not with another?
- Yes
- No

Question 5 of 10
Indicate the best erections achieved during sexual encounter in the last 6 months without the use of ED medication:
- 50% (too flaccid, unable to penetrate)
- 65% (firm enough for penetration but with difficulty most of the time)
- 80% (able to penetrate fairly easily most of the time)
- 90% (almost a complete erection)
- 100% (a rock hard erection)

Question 6 of 10
Indicate how often you can achieve this best erection:
- Rarely
- Sometimes
- Most of the time

Question 7 of 10
Indicate your best masturbatory erections in the last 6 months, using the scale listed above

Question 8 of 10
Indicate how frequently you experience morning erections:
- Strong and lasting
- Partial and short-lived

Question 9 of 10
Do you have problems controlling your ejaculation since the onset of ED?
- Yes
- No

Question 10 of 10
What, in your opinion has caused your problem?

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