AHMU Health & Household
Menu
Home
Weight Loss
Period Delay
Dental Infections
Erectile Dysfunction
0
Premature Ejaculation Form
Premature Ejaculation Form (#22)
Premature Ejaculation Form
Please Enter Your Date of Birth
Please upload your picture ID Proof (Driving License/ Passport) for Verification.
Choose File
Please Enter your sex at Birth
Male
Female
Please Enter Name of your GP
Please Enter the Full Address including Post code of your GP
Address Line 1
City
Post Code
Are you able to make your own healthcare decisions?
Yes
No
Enter Your Preferred Units For Height & Weight
- Select -
cm / Kg
ft' inches'' / lbs
Please Enter your Height (in cm)
Please Enter your Height (in ft'inches For e.g: 5'11'')
Please Enter your Current weight in kg
Please Enter your Current weight in lbs
Do you usually ejaculate sooner than you would like, often within around 1–2 minutes of penetration?
Yes
No
Have these symptoms been present for at least 6 months?
Yes
No
Does this cause you distress or impact your relationship or confidence?
Yes
No
Before ejaculation, do you have difficulty getting or keeping an erection?
Yes
No
Do you have any pain or discomfort when passing urine or during ejaculation?
Yes
No
We may advise GP review to rule out infection or prostate issues.
On average, how often are you sexually active?
Less than once per week
1–2 times per week
3–4 times per week
More than 4 times per week
Have you ever been diagnosed with any of the following?
Heart problems (including heart failure or rhythm problems)
History of fainting
Low blood pressure
Liver problems
Epilepsy or seizures
Depression
Bipolar disorder or mania
Schizophrenia or other psychiatric condition
None of the above
Do you have any of the following health conditions?
Diabetes
Pre-diabetes
High blood pressure
High cholesterol
Obstructive sleep apnoea (OSA)
Angina, coronary heart disease (CHD) or heart attack
Transient ischaemic attack (TIA) or stroke
None of the above
Do you sometimes feel dizzy or light-headed when standing up quickly?
Yes
No
Have you ever been told you have very low blood pressure (below 90/50 mmHg)?
Yes
No
Unsure
Are you currently taking any prescription, over-the-counter, herbal or recreational substances?
Yes
No
Please list all medications and supplements, including antidepressants, pain relief, erectile dysfunction treatments, or recreational drugs.
Do you have any allergies to medications, especially Dapoxetine or similar medicines?
Yes
No
Please provide details of allergies
Do you drink alcohol?
Yes
No
Alcohol must be avoided on days you take this medication due to increased risk of fainting.
Do you smoke or use nicotine products (including vaping)?
Yes
No
Have you tried anything before for premature ejaculation?
No
Behavioural techniques
Counselling or therapy
Medication
Combination
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
I confirm!
Select Products
Priligy Tablets
Submit
