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
<-- duration
<-- nausea
<-- vomiting
<-- diarrhea
<-- fever
<-- abdominal pain
<-- hematemesis
<-- hematochezia
<-- melena
<-- adequate urine output
<-- exposures
Past history of GI problems
<-- infectious diarrhea
<-- diverticulitis
<-- irritable bowel syndrome
<-- inflammatory bowel disease

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 1 form elements, 176 boilerplate words, 1 drop downs, 1 total clicks
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