mpresiados chart

FOUND
age: [textarea name="chartbox112" default=" " cols="5" rows="1"] [checkbox name="variable_1112" value="years old|months old|weeks old|days old"]
gender: [checkbox name="variable_1113" value="male|female"]
approximate weight: [select name="weight11" value="80|3|6|10|15|20|25|30|35|40|50|60|70|80|90|100|110|120|130|140|150|160|170|180|190|200|210|220|230|240|250|260|270|280|290|300|"] kgs
mental status: [checkbox name="variable_111115" value="alert and oriented x3 (name/place/year)|alert and oriented x2 (name/place)|alert and oriented x1 (name only)|at normal baseline of "][textarea name="chartbox1114" default="" cols="55" rows="1"]
position found: [checkbox name="variable_11154" value="ambulatory|sitting down|laying down"] [textarea name="chartbox115" default=" " cols="55" rows="5"]
respiratory status: [checkbox name="variable_11155" value="no obvious respiratory distress noted|mild respiratory distress|moderate respiratory distress|severe respiratory distress"] [textarea name="chartbox116" default=" " cols="55" rows="1"]
skin signs: [checkbox name="variable_11156" value="warm, dry, and pink|cool, pale, and diaphoretic|cool,clammy, and pale|cool, dry, and pale|hot, dry, and normal in color"] [textarea name="chartbox118" default=" " cols="55" rows="1"]

CHIEF COMPLAINT
[textarea name="chartbox2" default="" cols="55" rows="1"][checkbox name="variable_111557" value="weakness|fever|chest pain|shortness of breath|syncope|altered mental status"]

HISTORY
[textarea name="chartbox3" default="in summary - as related by patient: \n-" cols="155" rows="10"]

[checkbox name="variable_11156555" value="patient denies: |family denies: |patient and family denies: "][textarea name="chartbox4" default="" cols="155" rows="3"][checkbox name="denies2" value="loss of consciousness|blood thinners|head pain|midline neck pain|midline back pain|chest pain|abdominal pain|hip pain|extremity pain|falls|injuries|headache|dizziness|nausea|vomiting|blurred vision|numbness|tingling|chest pain|shortness of breath|abdominal pain|bloody stools|diarrhea|dysuria|hematuria|excessively foul smelling urine|change in frequency in urine|recent illnesses such as fever/cough/chills|infected wounds/cuts|itchy rashes|vaginal discharge|menstrual cycle irregularities|hip pain|leg pain|trauma|recent changes to medications|changes to diet|street drugs|alcohol use|auditory hallucinations|visual hallucinations|thoughts to harm self|suicidal ideations|thoughts to harm others|or any other complaints"][textarea name="pdenies1" default="." cols="155" rows="1"]

CLINICAL IMPRESSION
[textarea name="clinical1" default="1) " cols="155" rows="5"]

[checkbox name="Refusal2" value="Patient adamantly refused any further treatment and transport by EMS multiple times (x3). Patient verbally acknowledges the risk of further ailment when refusing EMS. Patient verbally acknowledges and signs EMS refusal form with an understanding. Patient advised to seek further medical evaluation and to call 911 if needed.
"]