Premature ejaculation - Consultation

What is your date of birth?

What is your gender?

Are you able to make your own healthcare decisions?

Yes

What is your current height ?

Allowed values range from 100cm to 220cm

Switch to ft, in

What is your weight ?

Allowed values range from 40kg to 250kg

Switch to st, lb

Do you usually ejaculate sooner than you would like, often within around 1–2 minutes of penetration?

Yes

Have these symptoms been present for at least 6 months?

Yes

Does this cause you distress or impact your relationship or confidence?

Yes

Before ejaculation, do you have difficulty getting or keeping an erection?

Yes

Do you have any pain or discomfort when passing urine or during ejaculation?

Yes

On average, how often are you sexually active?

Have you ever been diagnosed with any of the following?

Do you sometimes feel dizzy or light-headed when standing up quickly?

Yes

Have you ever been told you have very low blood pressure (below 90/50 mmHg)?

Are you currently taking any prescription, over-the-counter, herbal or recreational substances?

Yes

Do you have any allergies to medications, especially Dapoxetine or similar medicines?

Yes

Do you drink alcohol?

Yes

Do you smoke or use nicotine products (including vaping)?

Yes

Have you tried anything before for premature ejaculation?

Do you have any other medical conditions not mentioned above?

Please list any other medicines or supplements not already included.

Is there anything else you would like the prescriber to know? (Optional)

Please confirm the following:

I understand this medication is taken 1–3 hours before sexual activity and not more than once in 24 hours.
I understand I must avoid alcohol when taking this medication.
I understand I must stop treatment and seek urgent medical help if I experience seizures, fainting, or significant mood changes.
I understand that if I feel dizzy after standing, I should lie down immediately and raise my legs.
I confirm the information I have provided is accurate and complete.
I understand that a UK-registered prescriber will review my consultation before any prescription is issued.
I confirm I am aged between 18 and 64.
I agree to the terms and privacy policy.

I confirm that I understand and agree to the above

To support safe prescribing please provide your GP details.

Yes

Would you like us to inform your GP of this consultation?

Yes

Do you give consent for us to contact your GP if required for clinical safety?

Yes