Patient reports things have been [select name="variable_1" value="getting better|getting worse|just about the same"] since the last visit.

Neurovegetative Symptoms: 
sleep is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; 
appetite is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; 
energy levels are [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; 
concentration is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"].

[textarea name="variable_1" default="sample text"]
Alert and Oriented: [select name="variable_1" value="x4|x3|x2|x1"]
Appearance: [select name="variable_1" value="Appropriately dressed/well groomed|disheveled|inappropriately dressed|neglected"].
Attitude toward the therapist: [select name="variable_1" value="cooperative|guarded|suspicious|paranoid|paranoid|warm"].
Eye contact: [select name="variable_1" value="Good|Fair|Poor|Fleeting|Avoidant"].
Psychomotor activity: [select name="variable_1" value="retardation|agitation|none"].
Speech: [select name="variable_1" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous"].
Thought process: [select name="variable_1" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous"].
Thought Content: [text name="variable_1" default="sample text"].
Mood: [text name="variable_1" default="sample text"].
Affect: [select name="variable_1" value="congruent with mood, stable|blunted|flat|incongruent with mood"].
Perception: [select name="variable_1" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preocuppied with delusions|preocuppied with thoughts"].
Suicidal Ideation: [select name="variable_1" value="none present|passive ideation, no plans or intent|activally suicidal"].
Homicidal Ideation:[select name="variable_1" value="no homicidal ideation|current homicidal ideation"]
Insight: [select name="variable_1" value="good|fair|poor"].
Judgement: [select name="variable_1" value="good|fair|poor"]

[textarea name="variable_1" default="sample text"]

Patient was scheduled for an appointment on [text name="variable_1" default="sample text"].
Prognosis: At the time of writing, patient's prognosis is [select name="variable_1" value="good|fair|poor|uncertain"] and continued treatment is [select name="variable_1" value="recommended|not recommended|Cdsds"].
[textarea name="variable_1" default="sample text"]
Patient reports things have been since the last visit.

Neurovegetative Symptoms:
sleep is ;
appetite is ;
energy levels are ;
concentration is .

Alert and Oriented:
Appearance: .
Attitude toward the therapist: .
Eye contact: .
Psychomotor activity: .
Speech: .
Thought process: .
Thought Content: .
Mood: .
Affect: .
Perception: .
Suicidal Ideation: .
Homicidal Ideation:
Insight: .


Patient was scheduled for an appointment on .
Prognosis: At the time of writing, patient's prognosis is and continued treatment is .

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.77, 26 form elements, 71 boilerplate words, 3 text boxes, 3 text areas, 20 drop downs, 26 total clicks
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