Generic Consultation – Premature Ejaculation

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

Do you suffer from any allergies?

If so, please provide more information

Yes

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

Is this a repeat prescription?

Yes

Does premature ejaculation cause you personal distress or inter-personal difficulty with your partner?

Yes

Do you drink alcohol?

Please Note: You are eligible for treatment, however, you should avoid drinking alcohol when taking Priligy since together they can cause drowsiness

Yes

Do you suffer any pain whilst ejaculating, or do you have any difficulty or pain passing urine?

Yes

Have you taken Priligy 30mg at least 4 times previously without any side effects and found that this strength is insufficient at reducing premature ejaculation?

Yes

Do you ejaculate before you want to?

Yes

Does it take you less than 2 minutes to ejaculate after penetration?

Yes

Have you been suffering from premature ejaculation for more than 6 months?

Yes

Do you have low blood pressure (below 90/50)?

If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

Do you have a tendency to faint or get light-headed when you stand up from a lying position?

Yes

Are you allergic (hypersensitive) to Priligy or dapoxetine?

Yes

Have you ever suffered from any of the problems listed below?

mental health conditions such as depression, mania , bipolar disorder or schizophrenia
Heart conditions (e.g. angina, chest pain, heart failure, irregular heart beats, heart attack or narrowing of any heart valve)
a history of bleeding or blood clotting problems
a history of glaucoma or have been told you are at increased risk of glaucoma due to family history raised intraocular pressure
kidney problems
prostate problems
epilepsy
recurrent fainting
moderate or severe liver problems galactose intolerance, the Lapp lactase deficiency or glucose?galactose malabsorption
any serious medical condition which may require immediate hospitalisation

Yes

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

If so, please list the medications

Yes

Are you taking any of the following medications?

Any treatment for erectile dysfunction (e.g. Viagra,Sildenafil,Cialis, Levitra)
Serotonin reuptake inhibitors (citalopram, sertraline, fluoxetine, escitalopram,fluvoxamine)
Venlafaxine
Tricyclic antidepressants (TCAs) e.g. amitriptylline, imipramine, clomipramine, nortriptyline, lofepramine, doxepin and dosulepin.
Monoamine Oxidase Inhibitors (MAOIs) e.g. rasagiline, selegiline, moclobemide, phenelzine
St John's Wort (a herbal medicine)
Other medicines for depression
Medicines for mental health conditions other than depression - including Thioridazine (schizophrenia), Lithium (bipolar disorder)
Recreational drugs such as ecstasy, LSD, narcotics or benzodiazepines
Tryptophan (for sleep)
Tramadol (for pain)
5HT1 antagonists e.g. sumatriptan, rizatriptan and zolmitriptan (for migraines)
Antibiotics: erythromycin, clarithromycin, telithromycin, linezolid
Antifungals e.g. ketoconazole, itraconazole and fluconazole
Medicines for HIV, including amprenavir, atazanavir, fosamprenavir, nelfinavir, ritonavir and saquinavir.
Medicines to thin your blood, such as warfarin
Non steroidal anti inflammatory medicines such as ibuprofen or aspirin
Medicines used to treat high blood pressure and chest pain (angina) that can make you feel dizzy e.g. nitrates, verapamil, diltiazem, doxazosin, atenolol, metoprolol and bisoprolol (if you feel dizzy taking any blood pressure medication you should consult a doctor and not take Priligy)
Medicines for enlarged prostate such as tamsulosin and finasteride
Aprepitant used to treat nausea.

Yes

I understand that dapoxetine is not effective for erectile dysfunction. Taking dapoxetine with medications for erectile dysfunction is not recommended because it may increase the risk of low blood pressure

Yes

Do you understand that if you experience any side effects of treatment such as changes in mood or any seizures, you must discontinue treatment immediately and seek urgent medical attention from a doctor?

Yes

Do you understand that if you feel light headed soon after standing, you should immediately lie down so your head is lower than the rest of your body or sit down with your head between your knees until the symptoms pass? You should also ensure you do not rise too quickly after prolonged lying or sitting and do not drive or operate machinery if you experience these symptoms.

Yes

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

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