STI Soap

[text name="variable_1" default="CC"]
[radio name="variable_1" value="Symptomatic|Asymptomatic|Exposed to Partner with Symptoms"]
[text name="variable_1" default="Vaccines"]
[checkbox name="Vaccines and Date" value="Hep B :|Hep C:|Tdap:|HPV:|Prior HIV Test:|HBV status:|HCV status"]
[text name="variable_1" default="# of partners: "]

[text name="variable_1" default="Sex with"]
[checkbox name="variable_1" value="partner of the same sex|Bisexual Partner|IV Drug User| HIV+ Partner"]
[text name="variable_1" default="Ever:"]
[checkbox name="variable_1" value="Paid for Sex|Shared IV needles"]

[text name="variable_1" default="Last sex:"]
[text name="variable_1" default="#in 2 weeks:"]
[text name="variable_1" default="Condom Use:"]
[radio name="variable_1" value="Always|Sometimes|Never"]

[text name="variable_1" default="Do you"]
[checkbox name="variable_1" value="Use Alcohol|Use Tobacco|IV Drugs|Other Drugs"]

[text name="variable_1" default="Prior STD"]
[checkbox name="variable_1" value="BV|Chlamydia|Genital Warts|Gonorrhea|Herpes|HIV|NGU|PID|Syphillis|Trich"]

[text name="variable_1" default="LMP: "]
[text name="variable_1" default="Last PAP: "]
[checkbox name="variable_1" value="Normal|Abnormal"]
[text name="variable_1" default="Douche"]
[checkbox name="variable_1" value="Yes|No"]
[text name="variable_1" default="Current BCM:"]
[checkbox name="variable_1" value="EC|COC|Depo|Implant|IUD|Tubal Ligation|Condoms|Hysterectomy"]
Are you interested in Birth control?
[checkbox name="variable_1" value="Yes|No"]

[text name="variable_1" default="Physical Exam"]
[textarea name="variable_1" default="GENERAL: Well developed and well nourished Female, Alert and oriented x 3, in no distress.
HEENT: No nits, no hair loss, No adenopathy; No lesions, No erythema, No tonsillar exudate
Skin:Clear; no lesions/rashes
Abdomen: No tenderness to palpation; no rebound tenderness
GU: No lesions/rashes or erythema; Normal vaginal discharge; no lice, nits, or hairloss; No adenopathy.
No lesions, erythema, or discharge on cervix. No adnexal tenderness"]

Are you interested in Birth control?

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.41, 27 form elements, 6 boilerplate words, 15 text boxes, 1 text areas, 9 checkboxes, 2 radio buttons, 59 total clicks
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