Premature Ejaculation - Medical Assesment

If you have ordered this medication before, you can log in to fill up the questionnaire automatically. Our pharmacists have a few quick and easy questions to help issue your FREE online prescription

About You

Are you male aged between 18 - 64?

You must answer the question to continue
This treatment is only suitable for men aged 18 - 64.
 

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

You must answer the question to continue
We are unable to supply you with Priligy if you and/or your partner do not find your premature ejaculation distressing. Consult with your GP for other options.
 

Do you drink alcohol?

You must answer the question to continue
You are eligible for treatment, however, you should avoid drinking alcohol when taking Priligy since together they can cause drowsiness
 

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

You must answer the question to continue
We are unable to supply you with Priligy. Please consult your GP.
Symptoms

Do you have trouble achieving or maintaining your erection?

You must answer the question to continue
It does not appear that you have erectile dysfunction. We are unable to supply you with treatment. Please consult your doctor for more information.
Health

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?

  • If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery
You must answer the question to continue
We are unable to supply you with treatment if you have high blood pressure. Please consult your GP for more information.
 

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/GP surgery.
You must answer the question to continue
We are unable to supply you with treatment if you have low blood pressure. Please consult your GP for more information.
 

Have you been advised to avoid strenuous exercise?

You must answer the question to continue
We are unable to supply you with treatment. Please consult your GP for more information.
 

Would you have any difficulty walking at a fast pace for 5 minutes?

You must answer the question to continue
We are unable to supply you with treatment at this time. Please consult your GP.
 

Do you suffer from depression for which you have not seen a GP?

You must answer the question to continue
We are unable to supply you with treatment at this time. Please consult your GP.
 

Do you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously?

You must answer the question to continue
We are unable to supply you with treatment. Please consult your doctor for more information.
 

Have you ever suffered from any of the problems listed below?

  • Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).
  • Stroke
  • Sight loss due to poor circulation
  • Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)
  • Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells)
  • Stomach ulcers (e.g. peptic/gastric ulcer)
  • Liver problems
  • Kidney problems
  • An erection that lasted more than 4 hours
  • Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
  • Inherited eye disease - retinitis pigmentosa
  • Multiple myeloma (cancer of the bone marrow)
  • Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
  • Any serious medical condition which may require immediate hospitalisation
You must answer the question to continue
We are unable to supply you with treatment. Please consult your GP
Medication

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?

  • Often taken for chest pain/angina
  • Can be administered as a spray, tablet or patch.
  • Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate
You must answer the question to continue
We do not advise any recreational drug use with PDE 5 inhibitors, but especially nitric oxide donors such as ‘poppers’ which may lead to a dangerous fall in your blood pressure. We are unable to supply you with treatment. Please consult your doctor for more information.
 

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

You must answer the question to continue
 

Are you taking any of the following medications?

  • Any treatment for erectile dysfunction apart from Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil), Spedra (avanafil)
  • Medicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
  • Recreational drugs prohibited by law (Class A,B or C)
  • Recreational nitrates such as amyl nitrate also known as "poppers"
  • Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, doxazocin, prazocin terazocin & indoramin)
  • Medicines to treat high blood pressure.
  • Warfarin - used to to prevent heart attacks, strokes, and blood clots
  • Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir)
  • Nicorandil
  • Anti-fungal medication such as Ketoconazole or itraconazole
  • Quinidine/procainamide/amiodarone
  • Theophylline
  • Erythromycin/clarithromycin/cimetidine
  • phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).
You must answer the question to continue
We are unable to supply you with treatment. Please consult your GP.
Agreement

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?

You must answer the question to continue
Whilst these are uncommon side effects, they are very serious and you must discontinue use immediately. You must agree to this before continuing.
 

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.

You must answer the question to continue
An uncommon side effect of Priligy is that it can reduce your blood pressure and cause symptoms of light headedness. If you experience these symptoms, you must understand how to manage it and must discontinue the medication and seek medical attention immediately. You must agree to this before continuing.
 

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, if you start new medication or if 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 must answer the question to continue
You must agree to this before continuing. If you need assistance contact customer support.
 
You must click on the terms and conditions to continue
01273 204 905

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