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Date of Birth

What is your biological sex? (at birth)

Do you often ejaculate within 2 minutes of sexual penetration?

Yes

Are you looking to order oral tablets (Priligy) or a topical cream today?

Are you aged between 18-64?

Yes

Do you find it difficult to control when you are going to ejaculate?

Yes

Has premature ejaculation been a concern for you for six months or longer?

Yes

Is premature ejaculation affecting your relationship with your partner?

Yes

I understand that premature ejaculation can be caused by drinking too much alcohol, or using recreational drugs such as cocaine

Confirm

Yes

Have you ever dealt with any of the following health issues?

Epilepsy or seizure

Fainting

Dizziness when you stand up after lying down

Bleeding or clotting disorder

Any heart conditions

Problems with yours liver or kidney

Any mental conditions e.g. depression, anxiety, bipolar disorder, mania

None of the above

Please read the following information and tick to confirm that you understand the information provided

- Treat Erectile Dysfunction First: Address any issues with achieving or maintaining an erection prior to focusing on premature ejaculation. - Manage Hyperthyroidism: An overactive thyroid can contribute to premature ejaculation; ensure it's properly treated beforehand. -Check Prostate Health: Chronic prostatitis is common among men with premature ejaculation. Please ensure you have had a recent prostate exam before seeking treatment. - Consider Pelvic Floor Exercises: Strengthening pelvic muscles through exercises may help reduce premature ejaculation.

Yes

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

Yes

Do you have any allergies?

Yes

Is there any other information you feel would be useful for our clinicians to know about?

Yes

If you are looking to order Emla cream, please note: our doctors prescribe Emla for premature ejaculation for 'off-label' use. 'Off-label' means the medicine is being used in a way that is different to how it's described in the medical license of the product. You can read more information here. This information will also be provided in your delivery.

Please confirm you have read the above before proceeding.

Yes

Declaration

I am over 18 years old. I confirm this treatment is for me, and I consent to this treatment. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances. I agree to the DrWeightmans terms and conditions.

Yes

To support your care, we kindly ask for your GP details. If treatment is supplied, we may notify them. Providing accurate information helps avoid any delays.

Enter GP details Manually or search via GP postcode/name.

Yes

Assessment

Premature Ejaculation Consultation

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