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?

Have you taken Priligy 30mg at least 4 times previously without any side effects and found that this strength is insufficient at reducing premature ejaculation?

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

Any treatment for erectile dysfunction (e.g. Viagra,Sildenafil,Cialis, Levitra) Serotonin reuptake inhibitors (citalopram, sertraline, fluoxetine, escitalopram,fluvoxamine) Venlafaxine Tricyclic antidepressants (TCAs) e.g. amitriptylline, imipramine, clomipramine, nortriptyline, lofepramine, doxepin and dosulepin. Monoamine Oxidase Inhibitors (MAOIs) e.g. rasagiline, selegiline, moclobemide, phenelzine St John's Wort (a herbal medicine) Other medicines for depression Medicines for mental health conditions other than depression - including Thioridazine (schizophrenia), Lithium (bipolar disorder) Recreational drugs such as ecstasy, LSD, narcotics or benzodiazepines Tryptophan (for sleep) Tramadol (for pain) 5HT1 antagonists e.g. sumatriptan, rizatriptan and zolmitriptan (for migraines) Antibiotics: erythromycin, clarithromycin, telithromycin, linezolid Antifungals e.g. ketoconazole, itraconazole and fluconazole Medicines for HIV, including amprenavir, atazanavir, fosamprenavir, nelfinavir, ritonavir and saquinavir. Medicines to thin your blood, such as warfarin Non steroidal anti inflammatory medicines such as ibuprofen or aspirin Medicines used to treat high blood pressure and chest pain (angina) that can make you feel dizzy e.g. nitrates, verapamil, diltiazem, doxazosin, atenolol, metoprolol and bisoprolol (if you feel dizzy taking any blood pressure medication you should consult a doctor and not take Priligy) Medicines for enlarged prostate such as tamsulosin and finasteride Aprepitant used to treat nausea.

I understand that dapoxetine is not effective for erectile dysfunction. Taking dapoxetine with medications for erectile dysfunction is not recommended because it may increase the risk of low blood pressure

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.

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

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?