X  P  L  O  R
excellent role in male impotence
Mem. Registration
  Home  
     
  User Registration  
     
  Doctor's Reply  
     
  Men's Health  
     
  Orgasm  
     
  Pleasure  
     
  SDTs, STIs HIV/AIDS  
     
  F. A. Q.  
     
    Mission     Experts     Resources     Shopping     Contact Us

To find out if Sexual Therapeutic Care can help you, please complete all sections of this form in as much detail as possible. This will help us to make a more thorough initial assessment. Remember, this is free of charge. When we reply to your enquiry we will explain the treatment program and payment procedure if appropriate.
Please Provide the Following Information (Only for Male)

              *Compulsory field
  Name *
  Email Address *
  Country *
  Login Id * Max 15 Chars
  Please Identify and describe yourself
  Age(year)  *
  Relationship status
Single   Married   Cohabiting   Separated
  Sexual orientation
Heterosexual   Gay   Bisexual   Masturbation
   
  Nature of Sexual Problem*
Problems getting and / or maintaining an erection
For how long you have erection problem? Day Month Year
   
How it started? 
  Suddenly   Gradually
   
What happens on sex act?
No erection   Partial erection   Mixed of above
   
Do you feel pain when penis erected?
Yes   No
     
How many times if occurred?
All the times  Occasional
   
Usually I go into sex
  Times per   Day   Week   Month
   

Any other physical or mental illness present in?
You   Your Wife
   
Did you go into surgery (Lower abdomen / Penis / Prostate) before?
Yes   No
   
Are you taking any medicine?
Yes   No
   
Do you have any habit of following things?
Smoking   Alcohol   Addiction to street drug or any
   
Ejaculation Problem
Are you  not confident regarding your sex staying time
Yes   No
   
How fast ejaculation occurs?
Before introduction of intercourse  Before 5 seconds
  Before 10 seconds Before 15 seconds
Before 30 seconds Before 1 minute
Before 5 minutes Before 10 minutes
Before 15 minutes Before 30 minutes
Before  45 minutes Before  1 hour
If it is too fast then, for whom?
For you because you want increase your pleasure
For you partner because you want increase your partner's pleasure
For both because both of you want increase your pleasure
   
Have you talked to your partner about it?
Yes   No
I occasionally go for intercourse. 
It is roughly per  Day Week Month
Do you think premature ejaculation is due to your semen viscosity (Thickness), which has become clear and watery in recent days?
Yes   No
I am sterile (have no baby) and that may be due to premature ejaculation
Yes   No
My premature ejaculation is due to habit of excess masturbation
Yes   No
Size and shape of male organ
You are worried about size and shape of your penis because:
Your penis looks small  Yes   No
When your penis erected, then length measures    inches
During erection some area / point of my penis shows:
Bend/Curve   Weak   Hard
Growth / wound / some abnormal thing of my penis
You are worried about your testis, because:
The number of my testis is 
The size of testis is too  Big  Small
The position of one testis is in very  Up  Down
Some times my testis becomes very painful, hot and enlarged
I feel some thing in my testis
Discharge or bad sense in my urine passage
If you have any problem of discharge that comes out from the urine passage then answer following:
The thing that comes out from your urine passage looks:
Pus or Creamy or Whitish
Like white portion of an egg
Like blood
Such thing may be seen:
When I look my under cloth
When I go for toilet
Tick following if your answer is true:
I have history of an unprotected sexual intercourse
I have history of repeated attack of urine infection
I feel burning, scratching or pain in my urine passage
I feel very urgent when I have tendency for urine
I go for urine many times
I feel fever, chill and malaise
I feel pain or discomfort somewhere in between stool and urine passages or in my lower abdomen or in the lower back or in the lower back
  Write more, if you have to say
 

 
I declare that I am over 18 years of age and the information supplied above is accurate. I have read and understood the Terms and Conditions and confirm that I do not fall under the category of any restrictions.		  
  

   

 ©2008 sexproblembd.com. All rights reserved