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General

Assessment

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Premature Ejaculation

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You

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Are you registered with a GP practice in the UK? *

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? *

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare? *

Are you male and 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? *

Symptoms

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Do you have trouble achieving or maintaining your erection? *

Health

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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.

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.

Have you been advised to avoid strenuous exercise? *

Do you get chest pain or shortness of breath walking short distances, or up a flight of stairs? *

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

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), transient ischaemic attack, 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 or myeloma (blood cancer)
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

Medication

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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

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

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, alfuzosin, doxazosin, prazosin terazosin & 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, tipranavir)
Nicorandil
Anti-fungal medication such as fluconazole or Ketoconazole or itraconazole
Quinidine/procainamide/amiodarone
Theophylline
Erythromycin/clarithromycin/cimetidine
phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).

Agreement

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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? *

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Please sign in to continue

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