ROS 24 moths+

GENERAL: [checkbox name="variable_1" value=" + fatigue|+ Wt Gain|+ Wt Loss |+ Fever|+ Chills|+ Lethargy|+ Malaise||No fatigue|No Wt gain|No Wt Loss|No Fever|No Chills| No legargy| No malaise| "][text name="variable_1" default=", "]
EYES: [checkbox name="variable_2" value=" + pain|+ blurry vision|+ blindness|+ glasses|+coryza|+itching|+discharge || No pain|No blurry vision|No blindness|No glasses |no coryza| no itching|  no discharge"][text name="variable_2" default=", "]
ENT: [checkbox name="variable_3" value=" + hearing loss|+ aides|+ dentures|+ sore throat|+Ear pain| +Pulling at ears|+ sore tongue||No hearing loss|No aides|No dentures|No sore throat|no ear pain|No sore tongue"][text name="variable_3" default=", "]
CARDIAC: [checkbox name="variable_4" value=" + dizziness|+ palpitations|+ pedal edema|+ PND|+ Syncope|+ Claudication|+ SOB w/exertion ||No dizziness|No palpitations|No pedal edema|No PND |No Syncope|No Claudication| No SOB w/Exertion "][text name="variable_4" default=", "]
RESP: [checkbox name="variable_5" value=" + cough|+ chronic cough|+ sputum|+ SOB|+ Wheezing|+ O2 Use||No cough|No sputum|No SOB|No Wheezing|No O2 use|2 LPM|3 LPM"][text name="variable_5" default=", "]
GI: [checkbox name="variable_6" value=" + Abd Pain|+ Reflux|+ Anorexia|+ Dysphagia|+ Constipation|+ Diarrhea| + Nausea|+ Vomiting|+Loss Appetite||No Abd Pain|No Reflux|No Anorexia|No Dysphagia|No Constipation|No Diarrhea|No Nausea|No Vomiting|  No Change in appetite,|"][text name="variable_6" default=", "]
GU: [checkbox name="variable_7" value=" + Dysuria|+frequency|+ Hematuria| + Nocturia| + Incontinence|+ Urine Retention|+ Hx UTI||No dysuria|No Hematuria|No Nocturia|No Incontinence|No Hx UTI"][text name="variable_7" default=", "]
Musk: [checkbox name="variable_8" value=" + Arthralgias|+ Back Pain|+ Limb Pain|+ Myalgias|+ Weakness| + Independent Gait||No Arthralgias|No Back Pain|No Limb Pain|Ambulatory|No Myalgias|No Independent Gait|Non-ambulator"][text name="variable_8" default=", "]
Skin: 
[checkbox name="variable_9" value="+Dry skin| + Rash|+ Pruritus|+ Wounds|+New bumps| |No Dry skin| No Rash| No Pruritus| No Wounds| No new bumps"]
NEURO: [checkbox name="variable_10" value=" + Weakness|+ HA|+ Seizure|+ numbness| + Tremors||No Weakness|No HA|No Seizure|No numbness| No Tremors|"][text name="variable_10" default=", "]
PSYCH: [checkbox name="variable_11" value=" + Anxiety|No Anxiety|+ Depression|+ Difficulty sleeping|+ Hyperactivity ||No Depression| No difficulty sleeping|No hyperactivity"][text name="variable_11" default=", "]
GENERAL:
EYES:
ENT:
CARDIAC:
RESP:
GI:
GU:
Musk:
Skin:

NEURO:
PSYCH:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.52, 21 form elements, 11 boilerplate words, 10 text boxes, 11 checkboxes, 163 total clicks
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