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Medical Assessment for Premature Ejaculation Treatment

Complete this short online consultation so our medical team can show you suitable treatments.

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Tell us about yourself
Are you a male patient aged between 18 and 64 years old? (This information helps us confirm eligibility for treatment in line with safety and GPhC prescribing guidance.)
Do you regularly or occasionally drink alcohol?
Have you noticed pain when you ejaculate, or any problems such as pain or difficulty when passing urine?
Has premature ejaculation led to frustration for you, or contributed to any problems in your relationship?
Have you tried Priligy 30 mg on four separate occasions, experienced no side effects, yet felt that the 30 mg strength didn’t improve your symptoms enough?
About Your Symptoms
Do you often ejaculate earlier than you want to during sexual activity?
Do you usually ejaculate within two minutes of penetration?
Has premature ejaculation been an issue for you for at least the past six months?
Your Health Information
Have you ever had an allergic reaction to Priligy or its active ingredient, dapoxetine?
Do you ever feel faint or dizzy when standing up from lying down? We ask this because Priligy can lower blood pressure on standing, which increases the risk of fainting.
Is your blood pressure known to be low, specifically below 90/50 mmHg?
If you are unsure of your blood pressure, you can have it checked at your local pharmacy or GP surgery. Knowing your blood pressure is important before using Priligy because people with low readings (below 90/50) may be at higher risk of dizziness or fainting when taking this medication. You can learn more about blood pressure testing on the NHS website: https://www.nhs.uk/tests-and-treatments/blood-pressure-test/

Do you have a history of any of the conditions shown in the list below?

Mental health conditions (depression, mania, bipolar disorder, schizophrenia) - Priligy affects serotonin levels and may worsen or interact with existing mental health disorders.

Heart conditions (angina, chest pain, heart failure, irregular heartbeat, heart attack, narrowed valves) - Priligy can lower blood pressure and affect heart rate, which may be unsafe in heart disease.

Bleeding or clotting problems - Dapoxetine can increase bleeding risk in people with these conditions.

Glaucoma or raised eye pressure / family history of glaucoma - Priligy may slightly increase eye pressure, which can worsen glaucoma.

Kidney problems - reduced kidney function may lead to higher drug levels and increased side effects.

Prostate problems - existing urinary symptoms may be aggravated by Priligy.

Epilepsy - Priligy may increase the risk of seizures.

Recurrent fainting - because Priligy can cause drops in blood pressure, it may worsen fainting episodes.

Moderate or severe liver problems / galactose intolerance or related metabolic issues - poor liver function or metabolic disorders can affect how Priligy is processed, increasing risk.

Any serious condition requiring possible emergency hospital care - unstable or serious illnesses may make Priligy unsafe without close medical supervision.

Your Current Medication
Do you take any medicines or substances including prescription, non-prescription, or recreational drugs that we should be aware of before supplying treatment?
Patient Declaration & Agreements
Do you agree to the following? Please read each statement carefully before confirming. This ensures you understand how your treatment will be supplied and used safely.

☑️ I will read the Patient Information Leaflet provided with my medication before use.

☑️ I will contact ifeelshy and inform my GP immediately if I experience any side effects, start a new medication, or if my medical conditions change during treatment.

☑️ I understand that the treatment is for my personal use only and will not be shared with anyone else.

☑️ I confirm that I have answered all questions accurately and truthfully to the best of my knowledge.

☑️ I understand that the prescriber relies on my answers in good faith, and that providing incorrect or incomplete information could affect my health.

☑️ I understand that while treatment decisions are made jointly between myself and the prescriber, the final decision to issue a prescription rests with the prescriber.

Are you aware you and understand that if you experience mood changes, seizures, or any other side effects, you must stop taking the medication immediately and seek urgent medical care?
Are you aware and understand the actions to take if you feel light-headed after standing lie down or sit with your head lowered, stand up slowly from rest, and avoid driving or operating machinery if these symptoms occur.
I confirm that Priligy (dapoxetine) is not intended for erectile dysfunction (ED), and combining it with ED medication is discouraged because of the increased risk of low blood pressure.