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Premature Ejaculation

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2. Are you Male and over 18 and under 65 years old?

Medical History

3. Have you previously been diagnosed with premature ejaculation?

4. Do you ejaculate majority of the times within 2 minutes of vaginal penetration?

5. Do you suffer from persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before you wish?

6. Do you have poor control or difficulty over ejaculation?

7. Are you and/or your partner experiencing mental or emotional distress because of premature ejaculation?

8. Do you have a history of premature ejaculation in the majority of intercourse attempts over the last 6 months?

9. Are you currently receiving treatment for erectile dysfunction?

Please provide more details:

10. Do you have any of the following conditions?

  • Heart failure
  • Conduction abnormalities such as AV block or sick sinus syndrome
  • ischemic heart disease
  • valvular disease
  • A history of syncope or postural hypotension
  • A history of mania or severe depression.
  • Kidney or Liver disease/impairment
  • History of bipolar disorder, mania or severe depression
  • Uncontrolled epilepsy
  • Bleeding disorders
  • Raised intraocular pressure or at risk of angle closure glaucoma.
  • intolerance to galacotose, lapp lactase deficiency or glucose-galactose malabsorption.

Please provide more details:

Past Medical History

11. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Please provide more details:

12. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Please provide more details:

13. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Please provide more details:

14. Do you drink alcohol?

On average how much alcohol do you drink per day?
1 pint of beer or 2 small glasses of wine or less
More than 1 pint of beer or 2 small glasses of wine

15. Would you like us to pass on details of your treatment to your GP?

16. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Please click "Yes".