In order to assess whether erectile dysfunction (ED) medication is safe and appropriate foryou, we need to ask you a series of questions.
Your answers will help us both to understand the causes of your erection problems and to ensure that you are not taking medication or have medical conditions that could make ED medication unsafe.
Please answer as honestly and accurately as possible. If you cannot find an exact answer, choose the one that fits best – and use the free-text field at the end to provide any additional details.
We are required to store your information in accordance with health authority regulations, and we will treat your data securely and confidentially. Our doctors will also access your national medication record (including any privately marked medicines) when issuing a prescription.
Have you previously received a prescription through Potenslægen.dk?
1- Have you developed any new illnesses since last time?
2- Have you started any new medication since last time?
2a- If Yes, Choose type
3- Have you had your blood pressure measured since last time?
3a- Enter the reading
4- Are your erection problems unchanged since last time?
5- Have you noticed any new symptoms (e.g., premature ejaculation, reduced libido)?
6- Have there been any lifestyle changes (smoking, alcohol, weight)?
7- Anything else new you wish to tell the doctor?
1- Have you had a heart attack within the last 6 months?
1a- When did it occur?
2. Have you had a stroke within the last 6 months?
2a- When did it occur?
3. Are you currently undergoing active cancer treatment?
3a- What type of cancer?
4. Has your doctor advised you not to engage in physical or sexual activity?
4a- What exactly did your doctor advise against?
5. Have you experienced chest pain or discomfort during physical activity?
5a- When did it last occur, and during what activity?
6. Are you under 18 years of age?
7. Do you have a regular family doctor/GP?
1. Do you have problems getting or maintaining an erection?
1a- When did the problem begin?
1b- How did it start?
1c- Are the problems constant or do they vary?
2. Do you experience premature ejaculation during intercourse?
2a- Have you had this all your life, or did it start later?
3. Do you still have normal sexual desire/libido?
1. Have you recently felt affected by stress, anxiety, or depression?
1a- Please describe how it affects you.
1b- Are you in treatment for this?
1b.a- With ...
2. Have you noticed changes in your energy levels, fatigue, or physical condition?
2a- Please describe (e.g., fatigue, weight loss, reduced fitness).
3. Have you experienced frequent dizziness or fainting spells in the past 6 months?
3a- Have you lost consciousness, and did it happen during activity?.
4.1 Illnesses
Have you or have you ever had any of the following?
1. High blood pressure
2. Previous heart attack (please specify when)
2a- Are you on preventive treatment afterwards (e.g., blood thinners, heartmedication)?
3. Previous stroke (please specify when)
3a- Are you on preventive treatment afterwards (e.g., blood thinners, heartmedication)?
4. Other heart disease
4a- What type of heart disease?
5. Diabetes type 1 or 2
5a- How is it treated (diet, tablets, insulin)?
6. Cancer
7. Eye disease (e.g., glaucoma, retinitis pigmentosa)
8. Liver disease
8a- Have you had your liver function checked within the last year?
9. Kidney disease
9a- Have you had your liver function checked within the last year?
10. Sleep apnea
11. Asthma
12. Enlarged prostate
13. Other
4.1b Family history
Has anyone in your immediate family (parents or siblings) had:
1. Heart disease
2. Diabetes
3. Cancer
4. Eye disease
5. Liver disease
4.2 Medication
Do you take regular medication?
Nitrate medication (e.g., nitroglycerin, isosorbide, “poppers”)
Psychiatric medication (e.g., antidepressants, antipsychotics, anxiolytics)
Alpha- or beta-blockers (e.g., for high blood pressure or prostate problems)
Blood thinners (e.g., Warfarin, Eliquis, Xarelto)
Hormones or steroids (e.g., testosterone, anabolic steroids)
Other (please specify name and dosage)
If in doubt, you can check your medicine list at sundhed.dk or in the FMK app.
4.2b Allergies
Do you have any allergies to substances, medicines, or foods?
Please describe what you are allergic to and how you react.👉 We are especially interested in serious allergies and medication allergies(e.g., rash, swelling, breathing difficulties).
4.3 Urination and hormonal signs
1. Do you have problems fully emptying your bladder?
Have you discussed this with your doctor?
2. Do you suffer from phimosis (tight foreskin)?
3. Have you noticed breast development?
4. Have you noticed changes in your testicles (size, lumps, swelling)?
Please describe
1. Height (cm):
2. Weight (kg):
3. Have you had your blood pressure measured within the last 6 months?
Please enter the reading (e.g., 120/80)
4. Have you previously had low blood pressure (below 90/50)?
Have you experienced symptoms (e.g., dizziness, fainting) with this?
5. Do you smoke?
How many cigarettes per day, and for how long?
6. How much alcohol do you drink per week?
Please elaborate on your alcohol consumption.
7. How often do you exercise? (Never / Rarely / 1–2 times per week / 3+ times per week)
What type of exercise (e.g., walking, strength training, cycling)?
1. Have you previously used ED medication?
Why not?
Have you experienced side effects (e.g., vision problems, headache,chest pain)?
please elaborate if yes
2. Do you prefer a specific ED medication?
Why do you prefer this medication?
Here you will see an overview of all your answers.
You will have the option to go back and edit answers before submitting.
To continue, you must confirm all:
Full name:
ID number (CPR or equivalent):
Phone number:
Email:
Preferred contact method if the doctor has questions:
Is there anything else you would like to tell us about your health, medication, or symptoms?