[date name="variable_1" default="today" memo="date entered"]
[text name="variable_2" default="" memo="id"]
[date name="variable_3" default="today" memo="item date"]
[select name="variable_4" value="history|social history|family history|medication|exam|lab|imaging|consult|procedure" memo="item"]
[textarea name="variable_5" default="" memo="item detail"]