PE APPLICATION/SURVEY

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Tantra byron bay

~ Phone: 0425 347 477 ~

HOME
ABOUT EVE
PRIVATE SESSIONS
ONLINE COACHING
TESTIMONIALS
ARTICLES
- MISMATCHED LIBIDOS
- SEXUAL EMPOWERMENT
MORE

HOME
ABOUT EVE
PRIVATE SESSIONS
ONLINE COACHING
TESTIMONIALS
ARTICLES
- MISMATCHED LIBIDOS
- SEXUAL EMPOWERMENT
MORE

Premature Ejaculation Survey or Application form For A PE Private Session

Thank you so much for filling out this PE Form. This information is for two purposes.

1) To get to know you better, before we have a private session together AND/OR

2) To use in compiling research for my book on PE

All information is strictly confidential and will not be shared with any other party or any other purpose than listed above.

First Name:

Suburb/City/Country:

Contact Email:

Age:

Nationality:

This Information Is For A PE Session

YesNo

I Give Permission For The Information Below To Be Used In Research

YesNo

Do You Experience?

Primary PE - Present since the first time you had sex?Secondary PE - Recently required, after having satisfying sexual experiences previously?

At What Age Did You First Notice Symptoms of PE?

What Is Your Average Time Frame For Ejaculation During Sexual Stimulation With A Partner?

Less than 1 Minute?Less than 2 Minutes?Less than 5 Minutes?Less than 10 Minutes?Other?

What Is Your Average Time Frame For Ejaculation During Masturbation/Self Pleasure?

Less Than 1 Minute?Less Than 2 Minutes?Less Than 5 Minutes?Less Than 10 Minutes?Other?

What Is Your Frequency of PE?

20% of the time50% of the time80% of the time100% of the timeOther

Secondary PE - Did PE Begin Showing Symptoms In a Particular Relationship?

YesNo

Are You In A Committed Relationship?

How Long Have You Been In Relationship?

Are There Any Non Sexual Aspects Of Your Relationship That You Feel May Be Contributing To Your Experience Of PE?

What Has Been The Response of Your Partner To PE?

What Has Been Your Partner's Level Of Response To Your Treatment For PE?

No ResponseLow ResponseMedium ResponseHigh ResponseMore Than You

Has Your Relationship Finished As A Result of PE?

Are You On Any Prescribed Medication For PE?

What Other Medications Are You Currently On?

What Other Methods of Treatment For PE Have You Experienced?

Visited DoctorLotions/Topical ApplicationsSex TherapistTantra PractitionerOther

If Other Methods Are Employed, Please Detail:

What Exercises (If Any) Have You Been Practicing?

Do You Experience:

Delayed EjaculationErectile DisfunctionPsychological IssuesDepression/AnxietyTraumatic Experiences From Your ChildhoodSexual AbusePerformance AnxietyPsychotropic Drug Use

How Many Time Per Week Do You Have Sex?

None1234567More

How Many Times Per Week Do You Masturbate/Self Pleasure?

None1234567More

Do You Experience PE When You Masturbate/Self Pleasure?

YesNo

Do You Watch Porn?

YesNo

How Many Minutes Per Day Do You Watch Porn?

How Many Days Per Week Do You Watch Porn?

Have You Experienced Any Serious Physical Condition?

Heart Attacks/Angina?DiabetesCancerAsthma

Do You Currently Have A Penile Prosthesis Implantation?

NoYes

Is Your Partner?

FemaleMale

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Name*

Email Address*

Message

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Contact Phone:

(61) 0425 347 477

OCEAN SHORES

Byron Bay, NSW, 2483

Australia