Allergic Rhinitous 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|more than 1 month"] <-- duration
[select value="no|YES"] <-- nasal congestion
[select value="no|YES"] <-- nasal discharge
[select value="no|YES"] <-- sneezing
[select value="no|YES"] <-- watery eyes
[select value="no|YES"] <-- cough
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- past history of similar symptoms
Allergies identified 
[select value="no|YES"] <-- ragweed
[select value="no|YES"] <-- tree pollen
[select value="no|YES"] <-- mold
[select value="no|YES"] <-- grass
[select value="no|YES"] <-- animal dander
Prior treatment
[select value="no|YES"] <-- over the counter antihistamines
[select value="no|YES"] <-- loratidine
[select value="no|YES"] <-- fexofenadine
[select value="no|YES"] <-- cetirizine
[select value="no|YES"] <-- intranasal steroids
Past History
[select value="no|YES"] <-- asthma
[select value="no|YES"] <-- eczema
[textarea]