1 - How often are you climaxing sooner than you would like during sex?*

2 - What performance results are you looking for?*

3 - Over the past month, how was your control over ejaculation during sexual activity?*

4 - How distressed are you by how fast you ejaculate?*

5 - Over the past month, how was your satisfaction with your sex life?*

6 - To what extent does how fast you ejaculate cause difficulty in your relationship(s)?*

7 - Have you experienced fast ejaculation during all or almost all sexual activity since you became sexually active?*

8 - Have you ever been treated for premature ejaculation?*

9 - Have you tried any of these medications? *

10 - Was your past treatment effective?

11 - If you took any past treatments, did you have difficulty achieving or maintaining your erection until you ejaculate during sexual activity?*

12 - If you took any past treatments, did you experience any bothersome side effects?

13 - Do you experience any of the following cardiovascular symptoms?*

14 - Have any of your first degree relatives (parents or full siblings) ever attempted suicide or been diagnosed with bipolar disorder, hypomania, mania or major depression?*

15 - What was your last blood pressure reading?

16 - Do you have or have you previously been diagnosed with any of the following?*

17 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

18 - Do you take any medicines, vitamins, or supplements?

19 - Please list any allergies you have.

20 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

21 - How many uses per month do you anticipate? *

22 - Do you have a preference on medication type? *

23 - Do you have a preferred dose or strength?

24 - Do you have a preference on how often you'd like your medication?*

25 - Please enter preferred pharmacy information.*