High Blood Pressure Screening Form

[comment memo="High Blood Pressure Screening Form"]

[comment memo="Personal Information"]
Full Name: [text name="full_name"]

Date of Birth: [date name="dob"]

Gender: [radio value="Male|Female|Other"]

[comment memo="Blood Pressure"]
Please enter your most recent blood pressure readings:

Systolic: [text name="systolic_bp"] mmHg
Diastolic: [text name="diastolic_bp"] mmHg

[comment memo="Risk Factors"]
Please indicate any of the following risk factors you have:

[checkbox name="risk_factors" value="Family history of hypertension|Overweight or obesity|Unhealthy diet|Physical inactivity|Smoking|Excessive alcohol consumption|Stress"]

[comment memo="Additional Symptoms"]
Do you experience any of the following symptoms?

[checkbox name="symptoms" value="Headaches|Dizziness|Chest pain|Shortness of breath|Fatigue"]

[comment memo="Medications"]
Please list any medications you are currently taking for high blood pressure:

[textarea name="medications" rows=3]

[comment memo="Submit"]
[link memo="Submit Form" url="https://www.example.com/submit" mark="submit-form"]

[mark name="submit-form"]
Thank you for completing the high blood pressure screening form. Your submission has been received.

High Blood Pressure Screening Form

Personal Information
Full Name:

Date of Birth:

Gender:

Blood Pressure
Please enter your most recent blood pressure readings:

Systolic: mmHg
Diastolic: mmHg

Risk Factors
Please indicate any of the following risk factors you have:



Additional Symptoms
Do you experience any of the following symptoms?



Medications
Please list any medications you are currently taking for high blood pressure:



Submit
Submit Form

submit-form
Thank you for completing the high blood pressure screening form. Your submission has been received.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 17 form elements, 63 boilerplate words, 3 text boxes, 1 text areas, 1 dates, 2 checkboxes, 1 radio buttons, 1 links, 7 comments, 18 total clicks
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