Premature Ejaculation

Are you male from birth aged between 18-64 years old ? *

Have you been diagnosed with premature ejaculation by your GP/ specialist? *

Have long have you had problems with premature ejaculation? *

How long do you ejaculate after penetrating your partner? *

How difficult is it for you to delay ejaculation? *

Do you ejaculate before you want to? *

Do you ejaculate with very little stimulation? *

Do you feel frustrated because you ejaculate before you want to? *

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

Do you notice any pain or discomfort in your genitals, after you pass urine or ejaculate? *

Do you have any problem getting or maintaining an erection that is sufficient for penetration? *

Do you feel dizzy, lightheaded, or faint when you stand up from sitting or lying down? *

Could you check your blood pressure while lying/ sitting down, then again after standing for 3 minutes? *

Have you ever been advised to avoid or abstain from sexual intercourse (either by a Doctor, Nurse or Pharmacist)? *

Are you taking any other medicines? This could be prescription medication, over the counter or herbal remedies. *

Do you suffer from any allergies? Do you have any known allergy to local anaesthetics (e.g., lidocaine, prilocaine, or similar creams)? *

Do you have or have you ever had any of the following? *

• Heart problems, such as heart failure or problems with the heart rhythm, conduction abnormalities such as AV block or sick sinus syndrome, significant ischemic heart disease, significant vaalvular disease
• History of fainting
• Mania (symptoms include feeling over?excited, irritable or not being able to think clearly) or severe depression
• Severe depression
• Bipolar disorder
• Schizophrenia
• Moderate or severe liver problems.
• Severe renal impairment
• Orthostatic hypotension
• Epilepsy
• Angle closure glaucoma
• History of bleeding or blood clotting problems

Do you or your partner have a history of methaemoglobinaemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency? *

Are there any skin rash, cuts, grazes or open wounds, sores, eczema, or irritation on the genital skin? *

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel our Doctors should be aware of? *

Do you take any of the following? *

• Medicines for depression called ‘monoamine oxidase inhibitors’ (MAOIs)
• Thioridazine used for schizophrenia
• Other medicines for depression (Nefazodone, St John’s wort)
• Lithium − a medicine for bipolar disorder
• Certain other antibiotics for treating infection (such as erythromycin, clarithromycin, telithromycin, Linezolid)
• Tryptophan − a medicine to help you sleep
• Tramadol − used to treat serious pain
• Medicines used to treat migraines (such as sumatriptan, rizatriptan and zolmitriptan)
• Certain medicines used to treat erectile dysfunction. (such as sildenafil, tadalafil or vardenafil)
• Certain other medicines for HIV (such as amprenavir and fosamprenavir, ritonavir, saquinavir, nelfinavir and atazanavir)
• Medicines to thin your blood (such as warfarin)
• Certain medicines used to treat high blood pressure and chest pain (angina) (such as verapamil and diltiazem, or enlarged prostate)
• Aprepitant − used to treat nausea.

Are you currently or have you previously been prescribed Priligy for premature ejaculation? *

If you have previously started treatment or got the supply elsewhere, please upload proof of previous use. Documents may include a prescription, dispatch note, label, or receipt, and must clearly show: *

• Order Date/ Prescription Date/ Dispatch Date Medication name and dosage
• Patient name or email address

Have you experienced any side effects or adverse reactions from previous use of medication for premature ejaculation? *

Is the prescribed dose sufficient to achieve the desired improvement in ejaculation? *

Can we share this information with your General practitioner? Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records. *

You understand that Priligy should be taken 1-3 hours before sexual activity is acticipated and not more than once in 24 hours. *

You understand that Priligy treatment should be started on the lowest dose, and only increased to 60mg strength if required. *

You understand you should not drink alcohol while taking Priligy. The effects of alcohol such as feeling dizzy, sleepy and having slow reactions, may be increased if taken with Priligy. This may increase your risk of injury from fainting or from other side effects *

You understand that dapoxetine (Priligy) can make you feel faint or cause your blood pressure to drop when you stand up. To reduce this risk, you should: *

• Take it with a full glass of water
• Avoid taking it if you’re dehydrated (e.g, if you haven’t had much to drink, or have been sweating, vomiting, or had diarrhoea or a fever)
• Stand up slowly from sitting or lying
• If you feel dizzy or unwell, lie down with your head low or sit with your head between your knees until you feel better.
• Avoid driving or using machinery if you feel faint.

You understand you should stop taking Priligy and see your doctor straight away if you experience: *

• Fits/Seizures
• Faint or feel light headed when you stand up
• Any changes in your mood
• Any thoughts of suicide or harming yourself

You 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 *

You understand that alcohol and Priligy together can increase the likelihood of low blood pressure and can increase the effects of alcohol. *

You understand you should avoid drinking grapefruit juice within 24 hours prior to taking Priligy as this can increase the level of this medicine in your body *

You understand that EMLA should be applied as a thin layer (approx. 0.5g) to the glans penis 10-15 minutes before intercourse, then wiped off before penetration to reduce the risk of partner numbness. *

You understand that condoms are recommended to prevent partner transfer and numbness with the use of emla cream. *

You understand that emla is for external use only and should be kept away from eyes, mouth, and mucous membranes and not to use on broken, irritated, or inflamed skin. *

You understand there are a few self-help techniques: *

• Masturbating an hour or two before having sex
• Using a thicker condom to help reduce penile sensitivity
• Practicing deep-breathing techniques to temporarily interrupt the ejaculatory reflex
• Incorporating pauses during intercourse and diverting attention to non-sexual thoughts to delay climax

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

Do you agree to the following ? *

• The treatment is solely for your own use.
• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health.
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
• You will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will inform your doctor about any unusual side effects.
• You will not exceed the maximum daily dose of this medication
• I confirm I have the capacity to make decisions about my own health