Usma Clinic

Address

70, 2nd Floor, Vijay Block Near Laxmi Nagar Metro Station, Opp Piller No 49, Laxmi Nagar, Delhi - 110092

Email

info@usmaclinic.com

Phone

+91 - 8750800100

What’s Your Full Name

Hi, Name What is Your Phone Number

Enter Your Email Id

What is your relationship status?*

Single Married Other

Height

Weight

What Problem Are You Facing*
Select All that apply

Erection problems Ejaculatory problem (early/delayed/no erection) Low sexual desire Excessive masturbation Others

Have you had sexual intercourse?*

Yes, I have successfully had sexual intercourse I have tried sexual intercourse but have never been sucessfull No, I have never tried sexual intercourse

In the last 6 months, how often have you had sexual thoughts involving a partner?*

Not at all A few times in a month A few times in a week Multiple times in a week Atleast once a day

In the last 6 months, how would you rate your satisfication with your level of interest in sexual activity?*

Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied

In the last 6 months, are you able to sustain your sexual desire when Engaging in sexual activity - with or without partner?*

almost never or never A few times Sometimes Most times Almost always or always

Are you unsatisfied with your erection during sexual intercourse?*

Yes No

In the last 6 months, how often are you able to get an erection during sexual activity (with or without partner)?*

almost never or never A few times Sometimes Most times Almost always or always

Whether The penis is Full of Erected at the time of erection or Not

Yes No

In the last 6 months, how often are you able to sustain the erection till ejaculation?*

almost never or never A few times Sometimes Most times Almost always or always

What concerns are you experiencing with respect to ejaculation?*

Early ejaculation Delayed ejaculation Unable to ejaculation/orgasm

How frequently you were able to control your ejaculation During penetrative sexual intercourse in last 6 Months?

almost never or never A few times Sometimes Most times Almost always or always

How often have you been satisfied with sexual intercourse in the last 6 months?*

almost never or never A few times Sometimes Most times Almost always or always

How Much retention While During Intercourse*

1 ejaculate before penetration Under 1 min 1 to 2 min 2 to 5 min

Have you been diagnosed with any of the following illness or disorders?*
Select all that apply

No long term illness or disorders Cardiac issues Diabetes Hypertension OTHER

Do you consume any of the following?*

None of the following Alcohol tobacco based products Cannabis(marijuana, weed etc) Nitrite poppers Steriods Recreational drugs(cocaine, herione, LSD)

All questions required