Motor Vehicle Accident History

Motor Vehicle Accident
This was a [text] velocity impact.  The vehicle impact was at the [text].
[select value="no|YES"] <-- Air bags deployed

Before the accident, the patient was seated [text] in relation to the vehicle.
Vehicle Restraints (e.g. seat belt): [text].
Extrication at the scene: [text]

[select value="no|YES"] <-- inside the vehicle after the accident.
[select value="no|YES"] <-- able to ambulate after the accident
[select value="no|YES"] <-- conscious during the accident
[select value="no|YES"] <-- remembers the impact
[select value="no|YES"] <-- remembers after the accident

Injury [text] prior to evaluation
Onset while: [text] 
Episode location: [text] 
Episode description: [text]

Associated Injuries: [text]
ROS
[select value="no|YES"] <--  seizure
[select value="no|YES"] <--  extremity weakness
[select value="no|YES"] <--  headache
[select value="no|YES"] <--  sensory changes (vision, hearing)
[select value="no|YES"] <--  shortness or breath
[select value="no|YES"] <--  chest pain
[select value="no|YES"] <--  nausea/vomiting
[select value="no|YES"] <--  incontinence of urine or stool
Motor Vehicle Accident
This was a velocity impact. The vehicle impact was at the .
<-- Air bags deployed

Before the accident, the patient was seated in relation to the vehicle.
Vehicle Restraints (e.g. seat belt): .
Extrication at the scene:

<-- inside the vehicle after the accident.
<-- able to ambulate after the accident
<-- conscious during the accident
<-- remembers the impact
<-- remembers after the accident

Injury prior to evaluation
Onset while:
Episode location:
Episode description:

Associated Injuries:
ROS
<-- seizure
<-- extremity weakness
<-- headache
<-- sensory changes (vision, hearing)
<-- shortness or breath
<-- chest pain
<-- nausea/vomiting
<-- incontinence of urine or stool

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.33, 3 form elements, 169 boilerplate words, 2 text boxes, 1 drop downs, 3 total clicks
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