This is a questionnaire* to help identify men who may have a problem with ejaculating too soon during sexual activity. Even if you do not have difficulties, please answer all the questions.
- Please select the number that best represents your answer for each of the questions below
- Please select only one number for each question
- Remember there are no right or wrong answers to these questions
- While your experiences may change from time to time, what we need to know is your general experience with intercourse.
PLEASE NOTE:
Ejaculation refers to the release of semen after penetration
(i.e. when your penis enters your partner)
Question 1. How difficult is it for you to delay ejaculation?
Not difficult at all
Somewhat difficult
Moderately
difficult
Very
difficult
Extremely
difficult
0
1
2
3
4
Question 2. Do you ejaculate before you want to?
Never or
almost
never
(0%)
Less than
half the
time
(25%)
About half
the time
(50%)
Over
half the
time
(75%)
Always or
almost
always
(100%)
0
1
2
3
4
Question 3. Do you ejaculate with very little stimulation?
Never or
almost
never
(0%)
Less than
half the
time
(25%)
About half
the time
(50%)
Over
half the
time
(75%)
Always or
almost
always
(100%)
0
1
2
3
4
Question 4. Do you feel frustrated because of ejaculating before you want to?
Not at all
Slightly
Moderately
Very
Extremely
0
1
2
3
4
Question 5. How concerned are you that your time to ejaculation leaves your partner unfulfilled?
Not at all
Slightly
Moderately
Very
Extremely
0
1
2
3
4
- A score of 11 or more is commonly found in men with PE; whilst this score is not, on its own, adequate to diagnose PE without
a clinical assessment from of healthcare professional, it is highly suggestive of PE - A score of 9 or 10 may be found in men with PE; it is a “borderline” score
- A score of 8 or less suggests that a man does not have PE
* Symonds T, Perelman MA, Althof S,et al. Development and Validation of a Premature Ejaculation Diagnostic Tool. European Urology 52 (2007) 565 – 573
17
1st – 4
2nd – 4
3rd – 4
4th – 3
5th – 3
Q 1. 0
Q2. 0
Q3. 4
Q4. 3
Q5. 4