Premature Ejaculation

About the Condition and Treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Do you have renal impairment (Kidney Problems)?

Yes

Have you ever had an allergic or anaphylactic reaction to tablets containing dapoxetine?

Yes

Do you have any severe allergies?
If yes, please describe the allergy/reaction

Please provide details in this box here...

Yes

Do you have a history of mania, bipolar disorder or severe depression?

Yes

Do you have any problems of galactose intolerance, Lapp lactase deficiency or glucose?galactose malabsorption?

Yes

Have you been previously diagnosed with Glaucoma?

Yes

Do you have any significant pathological cardiac conditions such as: • Heart failure (NYHA class II-IV) • Conduction abnormalities such as AV block or sick sinus syndrome • Significant ischemic heart disease • Significant valvular disease • A history of syncope.

Yes

Do you have hepatic impairment (liver problems)?

Yes

Are you taking any drugs for erectile dysfunction?

Yes

Have you been diagnosed with premature ejaculation problems?

Yes

Do you have any other forms of sexual dysfunction?

Yes

Have you ever experienced Orthostatic hypotension?

Yes

Please list all your current prescription medication including any medication you buy over the counter...

Do you take any current or repeat medicines? (eg. oral asthma tablets) If yes, please list them below...

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Premature Ejaculation

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