Allergy & Otolaryngology
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Patient is being seen for [checkbox name="variable_1" value="ear pain|ear drainage"]
[select name="variable_5" value="|Right ear|Left ear|Both ears"]
[select name="variable_1" value="|acute onset|gradual onset"]
Symptoms lasting x [select name="variable_2" value="1|2|3|4|5|6|7"] Days

[text name="variable_1" default=""]

Associated Symptoms:
[checklist name="variable_2" value=" fever|cough|runny nose|tinnitis|dizziness|hearing changes|frequent ear infections|ear drainage"]
[checkbox name="variable_4" value="+ qtip use|recent water activities|recent air travel |+ day car attendence|+ Hx of DM or immunosuppression"]


Treatment:
[checkbox name="variable_3" value="None|Tylenol|ibuprofen|qtip use|"]

[textarea name="variable_1" default=""]
Patient is being seen for


Symptoms lasting x Days



Associated Symptoms:




Treatment:


Result - Copy and paste this output: