Medical Assessment - Priligy (Dapoxetine) 30mg

About You
Are you male aged between 18 - 64?
Does premature ejaculation cause you personal distress or inter-personal difficulty with your partner?
Do you drink alcohol?
Do you suffer any pain whilst ejaculating, or do you have any difficulty or pain passing urine?
Your Symptoms
Do you ejaculate before you want to?
Does it take you less than 2 minutes to ejaculate after penetration?
Have you been suffering from premature ejaculation for more than 6 months?
Do you find it difficult to achieve or maintain an erection before ejaculation?
Your Health
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.
Do you have a tendency to faint or get light-headed when you stand up from a lying position?
Are you allergic (hypersensitive) to Priligy or dapoxetine?
Have you ever suffered from any of the problems listed below?
  • mental health conditions such as depression, mania , bipolar disorder or schizophrenia
  • Heart conditions (e.g. angina, chest pain, heart failure, irregular heart beats, heart attack or narrowing of any heart valve)
  • a history of bleeding or blood clotting problems
  • a history of glaucoma or have been told you are at increased risk of glaucoma due to family history raised intraocular pressure
  • kidney problems
  • prostate problems
  • epilepsy
  • recurrent fainting
  • moderate or severe liver problems galactose intolerance, the Lapp lactase deficiency or glucose−galactose malabsorption
  • any serious medical condition which may require immediate hospitalisation
Your Medication
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
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?
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.
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.


Complete our 2 minute questionnaire
We’re almost done!
Dr Oliver Large
To make sure this treatment is safe for you to take, we just need you to answer a few questions.
Dr Oliver Large
Confidential & Secure
  • Our prescribers will review your details in complete confidence
  • Your medication will be delivered in plain unlabelled packaging
  • Appears on your statement as “Mexpress”
  • All data is securely encrypted with 128bit SSL
Need help? If you need help with this medical assessment, contact our helpline:
0208 123 0508
or email us: help@medexpress.co.uk