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Premature Ejaculation

- tell us about your condition

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Intro

Medical

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What is your gender

Do you need help completing this questionnaire?

Yes

No

Do you believe that you have the capacity to make decisions about your own healthcare?

Yes

No

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

Yes

No

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

No

Please provide more detail.

Do you suffer from any allergies?

Yes

No

Please provide details including which allergies and what symptoms you experience.

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

Yes

No

Please provide more detail.

Are you male and aged between 18-60 years old?

Yes

No

Please provide more details

Do you often ejaculate within 2 minutes of sexual penetration?

Yes

No

Please provide more details

Does premature ejaculation cause you distress and/or interpersonal difficulties?

Yes

No

Please provide more details

Has your GP ever advised you that you are not fit enough for any physical or sexual activity?

Yes

No

Please provide more details

Do you understand that you cannot drink whilst using Priligy as it can cause drowsiness?

Confirm

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

Yes

No

Please provide more details

Do you suffer from low blood pressure (below 90/50) or experience faints or collapsing because of it?

Yes

No

Please provide more details

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

Yes

No

Are you allergic (hypersensitive) to Priligy (dapoxetine) or any other SSRI antidepressant medicines?

Yes

No

Please provide more details

Have you ever suffered from the following?

Problems with galactose intolerance
Recurrent fainting
Prostate problems
A history of glaucoma or have been told you are at increased risk of glaucoma due to family history raised intraocular pressure
Heart conditions (e.g. angina, chest pain, heart failure, irregular heart beats, heart attack or narrowing of any heart valve)
Mental health conditions, such as depression, mania , bipolar disorder or schizophrenia
A history of bleeding or blood clotting problems
Kidney problems
Epilepsy
Poderate or severe liver
Any serious medical condition which may require immediate hospitalisation Stomach or duodenal ulcers

Yes

No

Please provide more details

Problems with galactose intolerance
Recurrent fainting
Prostate problems
A history of glaucoma or have been told you are at increased risk of glaucoma due to family history raised intraocular pressure
Heart conditions (e.g. angina, chest pain, heart failure, irregular heart beats, heart attack or narrowing of any heart valve)
Mental health conditions, such as depression, mania , bipolar disorder or schizophrenia
A history of bleeding or blood clotting problems
Kidney problems
Epilepsy
Poderate or severe liver
Any serious medical condition which may require immediate hospitalisation Stomach or duodenal ulcers

Do you agree to the following?

you agree to the following?

I understand that Priligy can cause dizziness and confirm that I will not operate machinery or drive after taking this medication.
I will contact Cloud Pharmacy and inform my GP of your medication if I experience any side effects of treatment, If I start new medication or if your medical conditions change during treatment.
I confirm that when ordering the 60mg dose it is because the 30mg dose was not effective and I have not experience side effects.
I will read the patient information leaflet supplied with your medication and understand the risks and benefits of taking this medicine. I will contact a healthcare professional if I have any questions.
I will have my blood pressure checked regularly as I understand that low blood pressure can cause fainting or collapsing when taking Priligy.
I confirm that I will not take tablets for erectile dysfunction 24 hours of taking Priligy.
I confirm I will not continue to use Priligy for longer than 6 months without a medical review of my condition.
I have answered all the above questions accurately and truthfully. I understand that your prescribers take my answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to my health.

Confirm

Would you like us to notify your GP of the treatment you chose to order today?

Yes

No

GP Practice Name, GP Postcode, GP Telephone Number

GP Information

Please provide your GP surgery details.

Consent & Declarations

I confirm that my answers are true and accurate and that I have read and agree to the Terms and Conditions and Privacy Policy.

Its required to fill all details.

Do you agree to the following:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

Yes

No

Sorry we can't offer you this treatment, please contact your GP.

Please complete all required questions.

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