1. Can you always get an erection when you want one?
2. Do you get an erection in the morning?
3. Do you get an erection when you masturbate?
4. Do you sometimes have difficulty keeping an erection?
5. Have you had difficulties with erections for more than a year?
6. Have you ever taken any medication for erection before?
7. Have you had a blood pressure check during the last year?
8. Have you ever had a blood test for cholesterol?
9. Have you had a blood test for diabetes during the last year?
10. Has your mother, father, brother or sister had chest pain or a heart attack under the age of 60?
11. Do you understand the side effects, effectiveness and alternatives concerning the treatment you are requesting?
12. Do you request the treatment for your personal use only?
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