test

This visit was performed via telemedicine.
The employee confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider.
Verification of employee's identity was established.
Verbal consent was obtained for medical treatment in lieu of Covid-19 related pandemic.

The employee is being interviewed via video using Doxy.me

The employee is currently at [select name="variable_1" value="Home|Work|Other"]

The employee is a(an) [select name="variable_2" value= "RN|LPN|Respiratory Therapist|Nurse aid|Physician|Housekeeper|Radiology Technician|Dietary Worker|Registrar/Clerk|Maintenance|Security|Social Worker|Chaplain|PT/PTA/OT/OTA|Speech Therapist|Other"] at Mercy Medical Center.

The employee complains of a potential exposure to a Covid-19 positive patient.

The employee's exposure occurred on 
[date name="variable_3" default="04/18/2020"]

PPE utilized by the employee included 
[checkbox name="variable_4" value="gloves|surgical mask|N95 mask|goggles|face shield|gown|PAPR"]
The source of the potential exposure [select name="variable_5" value="wore a mask|did not wear a mask"]

The employee's last recorded temperature > 100.0F was [select name="variable_6" value="N/A|1|2|3|4|5|6|7|More than 7|"] days ago.

The employee's current symptoms include [checklist name="variable_7" value="subjective fever|chills|cough|sore throat|body aches|headache|nausea|vomiting|diarrhea|abdominal pain|dyspnea on exertion or at rest|chest pain|sore throat"]
Therapies tired:
[checkbox name="variable_8" value="Acetaminophen|Ibuprofen|OTC cough medication|multi-symptoms relief medications|lozenges|no treatment tried so far"]
[comment memo="Other:"][text name="variable_2" default=""]
This visit was performed via telemedicine.
The employee confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider.
Verification of employee's identity was established.
Verbal consent was obtained for medical treatment in lieu of Covid-19 related pandemic.

The employee is being interviewed via video using Doxy.me

The employee is currently at

The employee is a(an) at Mercy Medical Center.

The employee complains of a potential exposure to a Covid-19 positive patient.

The employee's exposure occurred on


PPE utilized by the employee included

The source of the potential exposure

The employee's last recorded temperature > 100.0F was days ago.

The employee's current symptoms include
Therapies tired:

Other:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.89, 10 form elements, 113 boilerplate words, 1 text boxes, 1 dates, 2 checkboxes, 1 check lists, 4 drop downs, 1 comments, 32 total clicks
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