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Patient ID Date MM slash DD slash YYYY 1. Significant Contributing factors Diabetes Hypertension Heart Disease High Cholesterol Obesity Smoking 2. Sexual History 2.1 Erectile Dysfunction Duration(months) Problems Achieving an erection Maintaining an erection Both Onset Acute Gradual Insidious Progression Slowly progressive Rapidly progressive Intermittent For the last 6 months, without ED treatment: Best sexual