Abdominal pain Rod

Patient presents for [text] onset  of abdominal pain x [text]. 

Location: [text]
Radiation: [text]
Severity [select name="variable_3" value="|Mild|Moderate|Severe"]

Characterized as: [text].

The pain is relieved with: [text]
The pain is exacerbated with: [text]

Associated Symptoms:
[select value="no|YES"] <-- decreased appetite 
[select value="no|YES"] <-- nausea
[select value="no|YES"] <-- vomiting [text]
[select value="no|YES"] <-- diarrhea
[select value="no|YES"] <-- constipation [text]
[select value="no|YES"] <-- black or bloody stool
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- Dysuria
[select value="no|YES"] <-- Frequency
[select value="no|YES"] <-- Hematuria

[checklist name="variable_1" value="Recent travel|recent abx use|sick contacts"]

Pertinent PMH
[checkbox name="variable_1" value="None|Gall Bladder or liver disease|GERD|PUD|Pancreatitis|Kidney stones|Frequent UTI's|Diverticulitis|IBS/IBD|PID|Vascular disease|AAA risk factor|pregnancy risk"]

Pertinent Past Surgeries:
[select value="no|YES"] <-- Hx of abdominal surgeries
[select value="no|YES"] <-- Appendectomy
[select value="no|YES"] <-- Cholecystectomy


Pertinent history:
[select value="no|YES"] <-- Excessive NSAIDs use
[select value="no|YES"] <-- Excessive Alcohol