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Reference code:

1. Are you dissatisfied with the length of time it takes to climax?

Very satisfied
Satisfied
Relatively satisfied
Dissatisfied
Never satisfied

2. Have you ever avoided sex for fear of embarrassment?

Never
Almost Never
A few times
Sometimes
Most times
Always

3. Has premature ejaculation caused relationship problems in the past?

Never
Almost Never
A few times
Sometimes
Most times
Every time

4. Has the fear of failure prevented you from meeting the opposite sex?

Never
Almost Never
A few times
Sometimes
Most times
Always

5. Have you ever used alcohol as a means of delaying ejaculation?

Never
Almost Never
A few times
Sometimes
Most times
All the time

6. Has the problem deteriorated over time?

Stayed the same
Partially
Moderately
Certainly
Severely

7. Do you struggle to satisfy your partner during sex?

Never
Almost Never
A few times
Sometimes
Most times
Always