1. How long have you had premature ejaculation?

   0-2 years
   3-5 years
   greater than 5 years

2. Have you ever been treated previously for premature ejaculation?

   Yes
   No

3. If you answered yes to question 2, how were you previously treated?

   anti depressant pills
   topical medication
   behavioral therapy
   other

4. If you answered no to question 2, why haven't you been treated previously?

   was unaware that treatment was available
   was too embrrassed to seek treatment.
   did not feet it was important enough to seek treatment
   other

5. How long does it characteristically take you to achieve orgasm?

   less than 1 minute
   1 - 2 minutes
   greater than 2 minutes

6. How long does it characteristically take you partner to achieve orgasm?

   less than 5 minutes
   5 - 10 minutes
   greater than 10 minutes

7. How long would you like to be able to maintain your erection prior to orgasm?

   2 - 5 minutes
   5 - 10 minutes
   greater than 10 minutes

8. Is you partner able to achieve orgasm through vaginal stimulation?

   Yes
   No

9. Do you have pain with ejaculation? Yes
   No

10. Do you have difficulty achieving or maintaining an erection?

    Yes
    No

11. Do you ever lose your erection prior to ejaculating?

    Yes
    No

12. Do you have any liver or kidney disease? Yes
    No

13. Do you have an allergy to lidocaine or any other local anesthetics?

    Yes
    No

14. Is your partner pregnant? Yes
    No

15. Do you have any rash or skin disorder involving the penis?

    Yes
    No

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