Premature Ejaculation Consultation

After penetration do you usually ejaculate within 2 minutes?

Does premature ejaculation directly or indirectly cause you distress within your sexual relationships or within any other part of your life?

Do you have any difficulty getting or maintaining an erection?

Have you or do you suffer with any of the following symptoms?
- Pain while ejaculating

- Difficulty passing urine

- Pain in the testes

- Feeling faint or dizzy when standing up after sitting or lying down

Do you suffer from low blood pressure (below 90/50) or ever fainted or collapsed due to your blood pressure?

Have you ever been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Is there any other information you would like to share with our prescribing team?

We strongly recommend that you inform your GP of any treatment you receive. Would you like Simply Meds Direct to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 75

- This treatment is for my use only

- I have the capacity to make decisions about my own healthcare

- I have understood all the questions and have answered this consultation truthfully and completely

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health

- I will read the patient information leaflet supplied with this medication

- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health

- I have read, understood and agree with our Terms and Conditions