PE Consultation Form – Digimed Pharmacy

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About You

1. Are you male aged between 18 - 64?

2. Do you drink alcohol?

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

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

5. 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?

Your Symptoms

6. Do you ejaculate before you want to?

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

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

Your Health

9. Are you allergic (hypersensitive) to Priligy or dapoxetine?

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

11. 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 or GP surgery.

12. 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 or 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

Your Medication

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

Agreements

14. 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

pressure a following?

15. 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?

16. 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.15. 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? (copy)

17. 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

Digimed

Premature Ejaculation Online Consultation

Please answer all questions truthfully and thoroughly to help our healthcare professional assess your suitability and avoid any delays in providing your medication.

Medical Assessment for Premature Ejaculation

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