Nursing COVID note for monitoring

Quarantine: [checkbox name="Quarantineintiated" value="Yes |No"]
Isolation: [checkbox name="Isolationintiated" value="Yes |No"]
Onset:[text name="Onset"]

Symptoms:
[checkbox name="Symptoms" value="Subjective fever|Chills|Congestion|Rhinorrhea|Sore Throat|Myalgias|Dry cough|Productive cough|Headache|Nausea|Vomiting|Diarrhea |Fatigue|SOB|None"]

Therapies tried:
[checkbox name="Therapies" value="Antipyretics|Cough meds|Nothing"]

COVID-19 QUESTIONS: Documented fever: [select name="variable_1" value="NO|YES"]
Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]
Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

PHYSICAL EXAM
[checkbox name="vitals" memo="Vitals" value=""][conditional field="vitals" condition="(vitals).is('')"]-Vitals - [select name="vitals1" value="reviewed, no remarkable abnormalities|significant for"][text size="50"]
[/conditional][checkbox name="briefexam" memo="Brief Visual Exam" value=""][conditional field="briefexam" condition="(briefexam).is('')"]-General - [text default="well developed, well nourished, no apparent distress" size="80"]
-HEENT - [text default="normocephalic, atraumatic, nares patent, mucous membranes moist" size="80"]
-Neck - [text default="Supple" size="80"]
-Abd - [text default="non-distended" size="80"]
-Ext - [text default="no cyanosis" size="80"]
-Neuro - [text default="appropriate balance, normal gait" size="80"]
-Psych - [text default="appropriate mood/affect" size="80"]
[/conditional][checkbox name="lungsdetailexam" memo="*" memo_size="small" value="-Lungs - "][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"][checkbox value="CTAB|no wheezes|no crackles|no rhonchi"]; [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examlungsabn1" value="WHEEZING-"][/conditional][conditional field="examlungsabn1" condition="(examlungsabn1).is('WHEEZING-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"][checkbox name="examlungsabn2" value="RHONCHI-"][/conditional][conditional field="examlungsabn2" condition="(examlungsabn2).is('RHONCHI-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"] [checkbox name="examlungsabn2" value="CRACKLES-"][/conditional][conditional field="examlungsabn2" condition="(examlungsabn2).is('CRACKLES-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"] [checkbox name="examlungsabn3" value="BREATH SOUNDS DIMINISHED-"][/conditional][conditional field="examlungsabn3" condition="(examlungsabn3).is('BREATH SOUNDS DIMINISHED-')"] [checkbox value="B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"];[/conditional][conditional field="lungsdetailexam" condition="(lungsdetailexam).is('-Lungs - ')"] [textarea memo="free text" memo_size="small" rows="2"]

PROVIDER NOTIFIED
[checkbox name="PROVIDERNOTIFIED" value="YES|NO"]
Provider Name
[text name="Providername"]