Patient Name: [text name="variable_1" default=""]
Room #: [text name="variable_2" default=""]

This is a [select name="age" value="|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100|"] y.o. [select name="variable_4" value="male|female"] with a past medical history of [text name="pmhx" default=""] scheduled for a [text name="proc" default=""].

[textarea name="variable_1" default=""]

[textarea name="variable_17" default=""]

BP: [text name="variable_44" default=""] mmHg; HR: [text name="variable_45" default=""] bpm; RR: [text name="variable_46" default=""] breaths/min; Temp: [text name="variable_47" default=""]C; SaO2: [text name="variable_48" default=""]% 

Na: [text name="variable_76" default=""] (N = 136-148 mmol/L) [checkbox name="variable_101" value="**ABNORNAL**"]
K: [text name="variable_77" default=""] (N = 3.5-5.2 mmol/L) [checkbox name="variable_102" value="**ABNORNAL**"]
Cl: [text name="variable_78" default=""] (N = 100-110 mmol/L) [checkbox name="variable_103" value="**ABNORNAL**"]
HCO3: [text name="variable_79" default=""] (N = 21-32 mmol/L) [checkbox name="variable_104" value="**ABNORNAL**"]
BUN: [text name="variable_80" default=""] (N = 5-23 mg/dL) [checkbox name="variable_105" value="**ABNORNAL**"]
Cr: [text name="variable_81" default=""] (N = 0.6-1.0 mg/dL) [checkbox name="variable_106" value="**ABNORNAL**"]
Gluc: [text name="variable_82" default=""] (N = 65-99 mg/dL) [checkbox name="variable_107" value="**ABNORNAL**"]

AST: [text name="variable_86" default=""] (N = 0-48 U/L) [checkbox name="variable_115" value="**ABNORNAL**"]
ALT: [text name="variable_87" default=""] (N = 13-61 U/L) [checkbox name="variable_116" value="**ABNORNAL**"]
TBili: [text name="variable_88" default=""] (N = 0-1.0 mg/dL) [checkbox name="variable_117" value="**ABNORNAL**"]
DBili: [text name="variable_89" default=""] (N = 0-0.4 mg/dL) [checkbox name="variable_118" value="**ABNORNAL**"]
APhos: [text name="variable_90" default=""] (N = 45-136 U/L) [checkbox name="variable_119" value="**ABNORNAL**"]

Hgb: [text name="variable_69" default=""] (N = 12-16 g/dL) [checkbox name="variable_108" value="**ABNORNAL**"]
Hct: [text name="variable_70" default=""] (N = 37-47%) [checkbox name="variable_109" value="**ABNORNAL**"]
WBC: [text name="variable_71" default=""] (N = 4.8-10.8 K/uL) [checkbox name="variable_110" value="**ABNORNAL**"]
Plt: [text name="variable_72" default=""] (N = 130-400 K/uL) [checkbox name="variable_111" value="**ABNORNAL**"]

Ca: [text name="variable_83" default=""] (N = 8.4-10.6 mg/dL) [checkbox name="variable_112" value="**ABNORNAL**"]
Mg: [text name="variable_84" default=""] (N = 1.4-2.4 mg/dL) [checkbox name="variable_113" value="**ABNORNAL**"]
PO4: [text name="variable_85" default=""] (N = 2.5-4.6 mg/dL) [checkbox name="variable_114" value="**ABNORNAL**"]

Other Labs:[text name="variable_91" default=""]

[textarea name="variable_21" default=""]

[textarea name="variable_93" default=""]
Patient Name:
Room #:

This is a y.o. with a past medical history of scheduled for a .



BP: mmHg; HR: bpm; RR: breaths/min; Temp: C; SaO2: %

Na: (N = 136-148 mmol/L)
K: (N = 3.5-5.2 mmol/L)
Cl: (N = 100-110 mmol/L)
HCO3: (N = 21-32 mmol/L)
BUN: (N = 5-23 mg/dL)
Cr: (N = 0.6-1.0 mg/dL)
Gluc: (N = 65-99 mg/dL)

AST: (N = 0-48 U/L)
ALT: (N = 13-61 U/L)
TBili: (N = 0-1.0 mg/dL)
DBili: (N = 0-0.4 mg/dL)
APhos: (N = 45-136 U/L)

Hgb: (N = 12-16 g/dL)
Hct: (N = 37-47%)
WBC: (N = 4.8-10.8 K/uL)
Plt: (N = 130-400 K/uL)

Ca: (N = 8.4-10.6 mg/dL)
Mg: (N = 1.4-2.4 mg/dL)
PO4: (N = 2.5-4.6 mg/dL)

Other Labs:



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.39, 54 form elements, 130 boilerplate words, 29 text boxes, 4 text areas, 19 checkboxes, 2 drop downs, 54 total clicks
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