Hospital Bed Checklist
[select name="Q1" value="No|Yes"] <-- Breathing issue such as COPD, CHF, Hypoxemia[conditional field="Q1" condition="(Q1).is('Yes')"]
[select name="Q1a" value="No|Yes"] <-- Patient has tried a bed wedge
[select name="Q1b" value="No|Yes"] <-- Patient has failed a bed wedge and head of bed must be elevated at a [text default="30"] degree angle[/conditional]

[select name="Q2" value="No|Yes"] <-- Diagnosis such as Cancer, Multiple Sclerosis, Parkinson Disease, Cerebrovascular Disease[conditional field="Q2" condition="(Q2).is('Yes')"]
[select name="Q2a" value="No|Yes"] <-- Patient is need of hospital bed for pain management and positioning in ways not feasible in an ordinary bed[/conditional]

[text] <-- Diagnosis codes related to needing the hospital bed
[text] <-- Length of need