History provided by [text] The patient has had cough for [text] days. Cough [select value="has not been productive|has been productive"]. Frequency is [select value="infrequent|intermittent|constant"]. Severity is [select value="minimal|moderate|severe"]. Fever [select value="is not present|is present"] Other characteristics include [checkbox value="sputum clear|sputum purulent|hemoptysis noted|harsh and barking quality|post-tussive emesis"]. Over the counter medications/remedies that have been tried are [text]. Patient has [select value="no known|known"] sick contacts at home, school, or work. Other symptoms: [checkbox value="sore throat|nasal congestion|earache|headache|myalgias"]. Other clues: [checkbox value="seasonal allergies|gastroesophageal reflux (GERD)"]. History of pulmonary problems: [checkbox name="pulmhx" value="no respiratory problems|frequent pneumonia|frequent bronchitis|asthma|other"][conditional field="pulmhx" condition="(pulmhx).is('other')"][text size=72 memo="<--describe other"][/conditional]. Tobacco: [checkbox name="tobacco" value="Patient is not a smoker|Patient is a current or former smoker|Patient is exposed to second hand smoke"][conditional field="tobacco" condition="(tobacco).is('Patient is a current or former smoker')"] [text size=72 memo="<--smoking details (optional)"][/conditional].
There are 17 form elements.