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Tantra byron bay

~ Phone: 0425 347 477 ~

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. 

This Information Is For A PE Session
I Give Permission For The Information Below To Be Used In Research
Do You Experience?
What Is Your Average Time Frame For Ejaculation During Sexual Stimulation With A Partner?
What Is Your Average Time Frame For Ejaculation During Masturbation/Self Pleasure?
What Is Your Frequency of PE?
Secondary PE - Did PE Begin Showing Symptoms In a Particular Relationship?
What Has Been Your Partner's Level Of Response To Your Treatment For PE?
What Other Methods of Treatment For PE Have You Experienced?
Do You Experience:
How Many Time Per Week Do You Have Sex?
How Many Times Per Week Do You Masturbate/Self Pleasure?
Do You Experience PE When You Masturbate/Self Pleasure?
Do You Watch Porn?
Have You Experienced Any Serious Physical Condition?
Do You Currently Have A Penile Prosthesis Implantation?
Is Your Partner?
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Thank you for contacting us. We will get back to you as soon as possible
This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you for contacting us. We will get back to you as soon as possible
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