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Your Health

About You

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation? *

Yes

What is your height? *

feet/inches

cm *

What is your weight? *

stones/lb

kg *

Stone *

What is your blood pressure? *

You must have had your blood pressure checked within the last 6 months, and be aware of the results. You are able to get your blood pressure checked at your GP surgery, or your local pharmacy. Can you please let us know what your latest blood pressure reading was. If you have not had your blood pressure checked within the last 6 months, you should have this checked. If you have hypertension for which you are taking medication, please indicate what your blood pressure reading is after taking medication.

Regular (90 over 60mmHg to 140 over 90mmHg)

Low (less than 90 over 60mmHg)

High (Over 140 over 90mmHg)

Not sure

Are you under the age of 18 or over the age of 64? *

Yes

Do you drink alcohol? *

Yes

Have you used dapoxetine (Priligy) before? *

Yes

Your symptoms

Do the following statements apply to you? *

Yes

It always takes me less than 2 minutes to ejaculate after penetration
I ejaculate before I want to
I have poor control over ejaculation
This has happened in most sexual encounters over the last 6 months
This causes me distress or problems in my sex life or relationship

Do you ever ejaculate before penetration occurs? *

Yes

Has this been a lifelong problem, meaning it has been present since you first became sexually active? *

Yes

Does you ejaculate prematurely every time you have sex or only sometimes? *

Every time with all partners

Sometimes with all partners

Sometimes with only some partners

Other

Do you ejaculate with very little stimulation? *

0 – Never or almost never

1 – Less than half the time

2 – About half the time

3 – Over half the time

4 – Always or almost always

Do you ever struggle to get or keep an erection firm enough for sex? *

Yes

How difficult is it for you to delay ejaculation? *

0 – Not difficult at all

1 – Somewhat difficult

2 – Moderately difficult

3 – Very difficult

4 – Extremely difficult

Do you ejaculate before you want to? *

0 – Never or almost never

1 – Less than half the time

2 – About half the time

3 – Over half the time

4 – Always or almost always

Do you feel frustrated because of ejaculating before you want to? *

0 – Not at all

1 – Slightly

2 – Moderately

3 – Very

4 – Extremely

How concerned are you that your time to ejaculation leaves your partner unfulfilled? *

0 – Not at all

1 – Slightly

2 – Moderately

3 – Very

4 – Extremely

In the last 3 months, have you had any urinary symptoms? *

Yes

Needing to pass urine more often than usual
Needing to rush to the toilet
Waking in the night to pass urine (nocturia)
A weak urine stream
Difficulty starting to pass urine
Needing to strain to pass urine
Feeling that your bladder does not empty fully

Have you recently had any of the following symptoms? *

Yes

Pain or burning when passing urine
Difficulty passing urine
Pain in the penis, testicles, or pelvic area
Pain when ejaculating
Fever or feeling feverish

Have you been diagnosed with a thyroid condition? *

Yes

Did your symptoms begin around any of the following? *

Yes

Stress or anxiety
Relationship issues
Performance worry
New medication or drug use

Your health

Have you been diagnosed with any of the following? *

Yes

Diabetes
Depression
Anxiety
Low mood affecting daily life

Do you ever feel dizzy or faint when standing up? *

Yes

Have you ever had any of the following? *

Yes

Heart conditions
Epilepsy
Liver disease
Blood clotting problems
Recurrent fainting

Do you have any other medical conditions? *

Yes

Your Medication

Are you currently taking any medication, supplements, or recreational drugs? *

Yes

Have you taken any of the following in the last 14 days? *

Yes

Antidepressants (SSRIs, SNRIs, TCAs)
MAO inhibitors
Linezolid
Thioridazine
St John’s wort
Antifungals (e.g. ketoconazole, itraconazole)
Antivirals (e.g. ritonavir)
Antibiotics (e.g. erythromycin)
Calcium channel blockers (e.g. verapamil, diltiazem)
Erectile dysfunction medicines
Non-steroidal anti-inflammatory medicines such as ibuprofen, diclofenac, naproxen, or aspirin
Aprepitant, used to treat nausea during cancer treatment
Medicines to thin blood, such as warfarin, apixaban, dabigatran, edoxaban, or rivaroxaban

A Bit More About You

IS THERE ANY ADDITIONAL INFORMATION THAT YOU WOULD LIKE TO PROVIDE, OR ANY QUESTIONS YOU HAVE? *

Yes

Agreement

Do you understand the following? *

Yes

Dapoxetine is taken only when needed, 1–3 hours before sex
Do not take more than one dose in 24 hours
Alcohol increases the risk of dizziness and fainting
It is not a treatment for erectile dysfunction
Combining with ED medicines may increase side effects
If you feel light-headed, sit or lie down
If you develop severe symptoms, stop and seek medical help

DO YOU AGREE THAT? *

Yes

You will read the Patient Information Leaflet supplied with your medication
You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You are over 18 and the treatment is solely for your own use
You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's.
By continuing, you agree to our Terms & Conditions, Cancellation Policy and Privacy Policy

CONSENT TO TREATMENT *

Yes

I confirm that the information I have provided is accurate and complete to the best of my knowledge, and I understand that this information will be reviewed by a qualified prescriber. I consent to receiving medical treatment, including the supply of prescription medication, if the prescriber deems it clinically appropriate.

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