Otalgia/ ear pain – Rod

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"]

Risk factors
[checklist name="variable_6" value="Recent/current URI| freuent ear infections | qtip use|recent water activities|recent air travel |day car attendence|Hx of DM or immunosuppression"]

[checkbox name="variable_3" value="None|Tylenol|ibuprofen"]

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

Symptoms lasting x Days

Associated Symptoms:

Risk factors


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.78, 9 form elements, 14 boilerplate words, 1 text boxes, 1 text areas, 2 checkboxes, 2 check lists, 3 drop downs, 25 total clicks
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