Gastroenteritis History

[select value="less than 1 day|1 day|2 days|3 days|4 days|5 days|6 days|7 days|more than 1 week"] <-- duration
[select value="no|YES"] <-- nausea
[select name="vomit" value="no|YES"] <-- vomiting[conditional field="vomit" condition="(vomit).is('YES')"]
[select value="no|YES"] <-- post prandial vomiting
[select value="no|YES"] <-- recurrent vomiting[/conditional]
[select name="diarrhea" value="no|YES"] <-- diarrhea[conditional field="diarrhea" condition="(diarrhea).is('YES')"]
[select value="1 to 5 times|6 to 10 times|more than 10 times"] <-- number of loose stools in the last 24 hours.[/conditional]
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- abdominal pain
[select value="no|YES"] <-- hematemesis
[select value="no|YES"] <-- hematochezia
[select value="no|YES"] <-- melena
[select value="yes|NO"] <-- adequate urine output
[select value="others with similar symptoms|others with Campylobacter|others with Giardia|others with Salmonella|recent travel out of the area|contaminated or possible contaminated food source"] <-- exposures
Past history of GI problems
[select value="no|YES"] <-- infectious diarrhea
[select value="no|YES"] <-- diverticulitis
[select value="no|YES"] <-- irritable bowel syndrome
[select value="no|YES"] <-- inflammatory bowel disease
[textarea]