[select name="variable_1" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- supine to sit
[select name="variable_2" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- sit to stand
[select name="variable_3" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- ambulation
[select name="variable_4" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- feeding
[select name="variable_5" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- toilet transfers
[select name="variable_6" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"] <-- grooming
[select name="variable_7" value="absent|present"] <-- dysphagia
[select name="variable_8" value="does not require|REQUIRES"] <-- tube feedings
[select name="variable_9" value="does not require|REQUIRES"] <-- IV antibiotics