pediatric sports physical HPI

[text memo="#"] year old [select value="male|female"] here for sports physical. Plans to play [text name="variable_1" default=""]. [select value="Has never|" Has previously] been denied for sports before. 
[text name="variable_1" default=""]

[select value="Denies|Reports"] history of asthma/wheezing. 
[select value="Denies|Reports"] history of Kawasaki. 
[select value="Denies|Reports"] recent diagnosis of mononucleosis.
[select value="Denies|Reports"] history of heart murmur. 
[select value="Denies|Reports"] history of diabetes. 
[select value="Denies|Reports"] history of covid [text memo="month/year if ever covid+"]

Hospitalization history: 
[textarea name="variable_1" default="none"]

Bone/Joint injuries: [textarea name="variable_1" default="none"]

Meds: 
[checklist name="variable_1" value="albuterol inhaler|epipen|glucagon|insulin"]

FamHx: 
[select value="Denies|Reports"] family history of genetic heart issues (HCM, MARFAN, QT, brugada)
[select value="Denies|Reports"] family history of sudden death <35 y/o

Allergies: 
[textarea name="variable_1" default="none"]
# year old here for sports physical. Plans to play . been denied for sports before.


history of asthma/wheezing.
history of Kawasaki.
recent diagnosis of mononucleosis.
history of heart murmur.
history of diabetes.
history of covid month/year if ever covid+

Hospitalization history:


Bone/Joint injuries:

Meds:


FamHx:
family history of genetic heart issues (HCM, MARFAN, QT, brugada)
family history of sudden death <35 y/o

Allergies:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.61, 18 form elements, 61 boilerplate words, 4 text boxes, 3 text areas, 1 check lists, 10 drop downs, 21 total clicks
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