Prescription Questionnaire - Premature Ejaculation

About You

1. Are you purchasing this medication for yourself?

Yes No

2. Are you Male and over 18 and under 65 years old?

Yes No

Medical History

3. Have you previously been diagnosed with premature ejaculation?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

9. Are you currently receiving treatment for erectile dysfunction?

Please provide more details:

Yes No

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:

Yes No

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:

Yes No

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

Please provide more details:

Yes No

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

Please provide more details:

Yes No

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

Yes No

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

Yes No

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.

Yes No

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".

Yes