Medical Assessment for Premature Ejaculation

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you male aged between 18 - 64?

Yes

This treatment is only suitable for men aged 18 - 64.

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Do you drink alcohol?

Yes

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

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

Yes

We are unable to supply you with Priligy. Please consult your GP.

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

Yes

We are unable to supply you with Priligy if you and/or your partner do not find your premature ejaculation distressing. Consult with your GP for other options.

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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

If you have not taken the lower strength version of Priligy before, you must not start treatment on the higher strength. This is because the lower strength is very effective for many men and has a much lower frequency and severity of side effects.

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Your Symptoms

Do you ejaculate before you want to?

Yes

We are unable to supply you with Priligy. Please consult your GP.

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

Yes

We are unable to supply you with Priligy. Please consult your GP.

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

Yes

We are unable to supply you with Priligy . Please consult your GP.

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Your Health

Are you allergic (hypersensitive) to Priligy or dapoxetine?

Yes

We are unable to supply you with Priligy. Please consult your GP.

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

Yes

We are unable to supply you with Priligy. Please consult your GP about this symptom for more information.

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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

We are unable to supply you with treatment if you have low blood pressure. Please consult your GP for more information.

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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

We are unable to supply you with treatment. Please consult your GP.

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Your Medication

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

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 prescriber and not take Priligy)
Medicines for enlarged prostate such as tamsulosin and finasteride
Aprepitant used to treat nausea.

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

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Agreement

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, you start new medication and/or 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
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

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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

Whilst these are uncommon side effects, they are very serious and you must discontinue use immediately. You must agree to this before continuing.

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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

An uncommon side effect of Priligy is that it can reduce your blood pressure and cause symptoms of light headedness. If you experience these symptoms, you must understand how to manage it and must discontinue the medication and seek medical attention immediately. You must agree to this before continuing.

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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

You must agree to this before continuing. If you need assistance contact customer support.

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Medical Assessment for Premature Ejaculation

To help us supply you with the most suitable treatment, please complete this online consultation.

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