URI=

[comment memo="HPI"]
Patient presents for evaluation of [text name= default=""][comment memo="duration"][text name= default=""]. Patient reports associated symptoms of [checkbox name= value="sore throat|non-productive cough|productive cough|nasal congestion|rhinorrhea|subjective fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain| ansomia |Dysgeusia |Appetite normal| Appetite decreased| normal wet nappies| decreased wet nappies"]

[checkbox name="variable_1" value="option A|option B|option C"]
Patient denies [checkbox name= value="sore throat|non-productive cough|productive cough|nasal congestion|rhinorrhea|subjective fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain|CP|SOB|LE edema|syncopy|Hemoptasis| ansomia |Dysgeusia |dyspnea"].

Patient reports [select name= value="no sick contacts|sick contacts"]. Patient has tried [checkbox value="nothing|acteminophen|ibuprofen|OTC cough medications|DayQuil"] for symptoms. 

[textarea name="variable_1" default="sample text"]

[checkbox value="+ tobacco use|No tobacco use|hx of asthma | No DVT risk factos"]


[select name= value="|Immunizations Up-to-date|Flu shot this season "]