Premature Ejaculation Registration Form
First Name
Last Name
Phone
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Email
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Do you have a Medicare Card?
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Yes
No
What is your Medicare Card Number?
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What is your Medicare Card Line Number?
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Please upload a copy of you Medicare Card
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Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Would you like us to let your GP know you have consulted with us and advise them of any medications we have prescribed?*
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Yes
No
Your GP's Name
Your GP's Clinic Name
Do you currently have any of the following medical conditions? (Select all that apply. Leave blank if none apply.
History of fainting
Severe Heart Disease
Manic Depression (Bipolar Disorder)
Severe Kidney or Liver Disease
Do you currently take any of the following medications? (Select all that apply. Leave blank if none apply.)
Antidepressants (SSRIs/MAOIs)
Strong Painkillers (Tramadol)
St John's Wort
Medications for Migraines (Triptans)
Do you have any allergies to medications?
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No
Yes
Please list the drugs you are allergic to
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PE Assessment
How long has premature ejaculation been an issue for you
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Since my very first sexual experience (Lifelong)
It developed recently after a period of normal function (Acquired)
It happens only occasionally or with certain partners
On averageRarely (less than 25% of the time), how long after penetration (penis entering partner) do you typically ejaculate?
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Rarely (less than 25% of the time)
Sometimes (25-50%)
Often (50-75%)
Always (75-100%)
How difficult is it for you to delay ejaculation?
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Not difficult at all
Somewhat difficult
Moderately difficult
Very difficult
Extremely difficult
Do you ejaculate with very little stimulation?
No
Yes
Does this cause you personal distress or frustration?
No
Yes, mildly
Yes, Significantly
Do you have difficulty achieving or maintaining an erection until completion of the sexual act?
No, my erections are firm and reliable.
Yes, I often lose my erection before I want to.
Sometimes
If you have an erection issue, does the PE happen because you are rushing to ejaculate before your erection fades?
Yes
No
Not sure
Treatment Preferences
Which of these would you be most interested in exploring? (Select all that apply)
On-Demand Tablet: Taken 1–3 hours before activity (e.g., Priligy/Dapoxetine).
Daily Tablet: A low-dose medication taken every day.
Topical Spray/Cream: Applied to the head of the penis to reduce sensitivity.
Non-medical techniques: Pelvic floor exercises (Kegels) or behavioral techniques.
Are you currently trying to conceive with a partner? (Note: Some PE medications can affect sperm motility; doctors need to know this.)
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No
Yes
Captcha
Consultation Fee for Non-Medicare Cardholders
*
GP Phone Consultation Fee
AU$75
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