Not difficult at all	Somewhat difficult	Moderately difficult	Very difficult	Extremely difficult
1) How difficult is it for you to delay ejaculation?	□ 0	□ 1	□ 2	□ 3	□ 4
	Almost never or never (0%)	Less than half the time (25%)	About half the time (50%)	More than half the time (75%)	Almost always or always (100%)
2) Do you ejaculate before you wish?	□ 0	□ 1	□ 2	□ 3	□ 4
3) Do you ejaculate with very little stimulation?	□ 0	□ 1	□ 2	□ 3	□ 4
	Not at all	Slightly	Moderately	Very	Extremely
4) Do you feel frustrated because of ejaculating before you want to?	□ 0	□ 1	□ 2	□ 3	□ 4
5) How concerned are you that your time to ejaculation leaves your partner sexually unfulfilled?	□ 0	□ 1	□ 2	□ 3	□ 4