Case Review

1. Name or Initials*

2. Your email (This is our main line of communication) *

3. Phone Number (Optional)*

5. Geographic Location (Current Country/Region of Residence)

6. Which pattern best describes your physiological response ( your premature ejaculation) during an intimate encounter?*

Autonomic Spike: Immediate heart-rate acceleration, shallow respiration, and involuntary climax within 30–60 seconds of initial contact.

Subconscious Script Loop: Baseline physiology functions normally during solitary tracking, but partner contact triggers hyper-vigilant overthinking, anticipatory anxiety, and an automated rapid response

Hyper-Sensitive Reflex Arc: Uniformly rapid response across all scenarios (both solitary and partner interaction) triggered by minimal sensory stimulation.

7. What is the historical timeline of this autonomic coordination error?*

Secondary / Acquired: It developed later in life following a specific period of high stress, burnout, or lifestyle transition.

Primary / Lifelong: It has occurred consistently across my entire sexual timeline since youth.

Undetermined: I require clinical data mapping to isolate my specific chronological pattern.

8. Which profile best reflects your current professional infrastructure and operational stress level?*

High Leverage / Peak Stress: C-Suite Executive / Corporate Leadership / Senior Partner at a Firm

High Output / High Stress: Tech Founder / Business Owner / Principal Investor

Specialized Precision / Moderate Stress: Licensed Medical Doctor / Attorney / Commercial Pilot / Specialized Engineer

Structured Corporate / Controlled Stress: Mid-Level Management / Corporate Professional

Independent / Variable Stress: Freelancer / Academic / Early Career Professional

9. Which first-line, short-term interventions have you previously deployed? (Select all that apply)*

Topical anesthetics / Numbing agents / Delay sprays or wipes

Daily or off-label SSRIs (e.g., Paroxetine, Sertraline, Lexapro)

Off-label metabolic prescriptions (e.g., Tramadol)

Natural botanical protocols, amino acids, or targeted supplements

None of the above

10. Have you previously invested in dedicated external support frameworks to resolve this issue?*

Yes — Private psychological counseling, talk therapy, or specialized clinical consultations.

Yes — Standard online direct-to-consumer digital subscription clinics (e.g., Roman, Hims).

No — I have primarily relied on unvetted public forums, subreddits, or generic pelvic/breathing exercises found online.

11. Did any of the historical interventions selected above yield a permanent, measurable extension of your latency baseline?*

Yes (Temporary or partial management only)

No (Zero long-term physiological shift)

12. On a scale of 0 to 10, quantify your mental and operational readiness to cure your premature ejaculation within the next 3 months.*

13. In 2–3 sentences, outline the current impact PE is having on your personal confidence, relationship stability, or daily cognitive bandwidth.*

Please fill out this form to get your case reviewed by Dr. Mond MH

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