The patient is being seen for cough x [text] [select name="variable_3" value="days|weeks|months"]. Cough is [checkbox name="variable_5" value="dry|Dry to productive|sputum clear|sputum purulent|hemoptysis noted|harsh and barking quality|post-tussive emesis"]
Frequency is [select value="infrequent|intermittent|constant"]. Severity is [select value="minimal|moderate|severe"]. Fever [select value="is not present|is present"][text name="variable_1" default=""]
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|preceding URI|nasal congestion|earache|PND|heartburn|headache|myalgias"].
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].