Consultation

Are you genetically Male?

Do ALL the following apply to you?

1. Time to ejaculatory after penetration is less than two minutes
2. Ejaculation occurs with minimal sexual stimulation before, on, or shortly after penetration and before wanted
3. Personal distress or interpersonal difficulty as a consequence of premature ejaculation
4. Poor control over ejaculation
5. Premature ejaculation in the majority of times intercourse was attempted over a 6 months period.

Do you have ANY of the following?

1. Heart problems, such as heart failure or problems with the heart rhythm
2. A history of fainting or dizzy episodes due to low blood pressure
3. Ever had mental health problem such as severe depression, mania (symptoms include feeling over-excited, irritable or not being able to think clearly), bipolar disorder (symptoms include serious mood swings between mania and depression) or schizophrenia (a psychiatric disease)
4. Other sexual problem, such as erectile dysfunction
5. Epilepsy
6. A history of bleeding or blood clotting problems
7. Susceptabliltiy to high pressure in the eye (angle closure glaucoma)
8. Moderate or severe liver OR Kidney problems
9. Rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption

Are you taking ANY of the following?

1. Medicines for depression called ‘monoamine oxidase inhibitors’ (MAOIs)
2. Thioridazine used for schizophrenia
3. Other medicines for depression
4. Lithium – a medicine for bipolar disorder
5. Tryptophan – a medicine to help you sleep
6. St John’s wort – a herbal medicine
7. Tramadol – used to treat serious pain
8. Medicines used to treat migraines.
9. Medicines for fungal infection, including ketoconazole, fluconazole and itraconazole
10. Medicines for HIV, including ritonavir, saquinavir, nelfinavir, fosamprenavir and atazanavir
11. Antibiotics for treating infection including telithromycin, linezolid, azithrmocyin and clarithromycin
12. Nefazodone – an antidepressant.
13. Medicines for mental health problems other than depression
14. Non-steroidal anti-inflammatory medicines such as ibuprofen or acetylsalicyclic acid
15. Medicines to thin blood, such as warfarin
16. Medicines used to treat erectile dysfunction, such as sildenafil, tadalafil or vardenafil, as these medicines may lower your blood pressure, possibly upon standing
17. Medicines used to treat high blood pressure and chest pain (angina) (such as verapamil and diltiazem), or enlarged prostate, as these medicines may also lower your blood pressure, possibly upon standing
18. Aprepitant – used to treat nausea.

If unsure, please contact your doctor or ask our pharmacist

Are you aware you should NOT take medicine to treat erectile dysfunction on the same day as Priligy?
These medicines include Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil) and Spedra (avanafil) tablets
Taken together they may cause low blood pressure and dizziness

Are you aware Priligy treatment should be started with one 30mg tablet, increasing to 60mg, if required?

Are you aware Priligy can lower blood pressure and cause dizziness in some men?

Are you aware you should stop taking Priligy and see your doctor straight away if:

1. You have fits (seizures)
2. You faint or feel light headed when you stand up
3. You notice any changes in your mood
4. You have any thoughts of suicide or harming yourself

Are you aware Priligy can affect the ability to drive and operate machinery in some men?

Are you aged 18 to 64?

Are you allergic to Priligy (Dapoxetine)?

Do the following apply to you?

1. The medication is for my own use
2. I will read the information leaflet supplied with the medication
3. I have completed this questionnaire myself and fully understand all the information
4. My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment
5. You will not consume grapefruit juice within 72 hours before or after taking Priligy
6. You will seek medical attention if you experience any unusual side effects
7. You will not drive or operate machinery if this medicine makes you dizzy, drowsy or affects your vision
8. I agree to the terms & conditions, privacy policy, & data sharing policy

What is the name of your GP surgery and do you consent to us contacting them about your treatment?

Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.