Diabetic Foot Ulcer History

History:
Onset:  [textarea]
Location:  [textarea]
Duration of Diabetes Mellitus:  [text]
Last A1c:  [text]
Risk Assessment
[select name="Q1" value="no|YES"] <-- Previous Foot Ulceration[conditional field="Q1" condition="(Q1).is('YES')"]
[textarea][/conditional] 
[select name="Q2" value="no|YES"] <-- Neuropathy (loss of protective sensation)[conditional field="Q2" condition="(Q2).is('YES')"]
[textarea][/conditional] 
[select name="Q3" value="no|YES"] <-- Foot Deformity[conditional field="Q3" condition="(Q3).is('YES')"]
[textarea][/conditional] 
[select name="Q4" value="no|YES"] <-- Peripheral Vascular Disease[conditional field="Q4" condition="(Q4).is('YES')"]
[textarea][/conditional] 
[select name="Q5" value="no|YES"] <-- Lower Limb Bypasses or Amputations[conditional field="Q5" condition="(Q5).is('YES')"]
[textarea][/conditional] 
[select name="Q6" value="no|YES"] <-- Tobacco Use[conditional field="Q6" condition="(Q6).is('YES')"]
[textarea][/conditional]