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