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?
3- Have you had your blood pressure measured since last time?
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?
2. Have you had a stroke within the last 6 months?
3. Are you currently undergoing active cancer treatment?
4. Has your doctor advised you not to engage in physical or sexual activity?
5. Have you experienced chest pain or discomfort during physical 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?
2. Do you experience premature ejaculation during intercourse?
3. Do you still have normal sexual desire/libido?
1. Have you recently felt affected by stress, anxiety, or depression?
2. Have you noticed changes in your energy levels, fatigue, or physical condition?
3. Have you experienced frequent dizziness or fainting spells in the past 6 months?
4.1 Illnesses
Have you or have you ever had any of the following?
4.1b Family history
Has anyone in your immediate family (parents or siblings) had:
4.2 Medication
Do you take regular medication?
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?
4.3 Urination and hormonal signs
1. Do you have problems fully emptying your bladder?
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)?
1. Height (cm):
2. Weight (kg):
3. Have you had your blood pressure measured within the last 6 months?
4. Have you previously had low blood pressure (below 90/50)?
5. Do you smoke?
6. How much alcohol do you drink per week?
7. How often do you exercise? (Never / Rarely / 1–2 times per week / 3+ times per week)
1. Have you previously used ED medication?
2. Do you prefer a specific ED 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?