pediatric chronic back pain

[text memo="#" size="5"] year old [select value="female|male"] here for [text memo="#"] [select value="weeks|months|years"] of [select value="worsening|stable|improving|waxing and waning"] [checkbox value="upper back|mid back|lower back"] pain. 
Patient describes pain as [checkbox value="aching|stiff|dull|sharp/shooting|burning|sore"] At its best, pain is a [text memo="#" size="5"]/10. At its worst, pain is a [text memo="#" size="5"]/10.  
Pain [select value="does not|does|sometimes"] radiate [checkbox value="into the L leg|into the R leg|around to the abdomen"] 
Pain is [checkbox value="constant.|intermittent.|constant with intermittent flares where it is worse."] On average, pain is present [text memo="#" size="5"] days per week, lasts [text memo="#" size="5"] hours per day. [select value="Denies|Endorses"] pain waking them from sleep. [text memo="woken from sleep # nights/week"]

Pain [select value="does not|does|sometimes"] interfere with daily activity. 

[checklist value="weight loss|fever|urinating/defecating on self|muscle weakness"]
[checkbox value="Pain does not seem to be especially bad in the morning or evening|Pain is especially bad in the morning|Pain is especially bad in the evening|Pain is especially bad at nighttime"]

Pain is alleviated/lessened by [textarea default=""]
Pain is provoked by/worsened by [textarea default=""]