[date name="variable_1" default="02/01/2019"]
Unit [select name="Dispatched_Unit" value="|Unit 21-01|Unit 22-01|Unit 23-01"] was dispatched to [select name="Origin_Facility_Name" value="|Clinton Memorial Hospital (Wilmington)|Highland District Hospital (Hillsboro)|Adena Greenfield Medical Center (Greenfield)|Adena Regional Medical Center (Chillicothe)|Miami Valley Hospital (Dayton)|UC Hospital (Cincinnati)|Bethesda North (Cincinnati)|Other"] [select name="Origin_Facility_Department" value="|Emergency Room|Telemetry Unit|Cardiac Unit|Other"] for a [select name="pre_scheduled" value="|Pre-Scheduled|Non Scheduled"] Advanced Life Support (ALS) [select name="var_001" value="|Non-Emergent|Emergent"] inter facility transfer of a [text name="Var_002" size="3"] year old [select name="var_004" value="|Male|Female"] patient to [select name="Destination_Facility_Name" value="|Clinton Memorial Hospital (Wilmington)|Highland District Hospital (Hillsboro)|Adena Greenfield Medical Center (Greenfield)|Adena Regional Medical Center (Chillicothe)|Miami Valley Hospital (Dayton)|UC Hospital (Cincinnati)|Bethesda North (Cincinnati)|Shriners (Cincinnati)|OSU Wexner Medical Center (Columbus)|Hearth & Care Center (Greenfield)|Edgewood Manor (Greenfield)|Grant Medical Center (Columbus)|Riverside Methodist (Columbus)|Childrens Medical Center (Cincinnati)|Other"] [select name="Destination_Facility_Dept" value="|Telemetry Unit|Cardiac Unit|Acute Care Burn Unit|Emergency department|Intensive Care Unit|Labor and Delivery|Other"] directed by sending physician for [checkbox name="var_005" value="|dialysis|discharge from facility|increased level of care or services not available at current facility|no beds available at current location|patient needs to be in a facility closer to family or other care givers|further testing|patient is already under care at receiving facility|Other:|"] for a transferring diagnosis of [select name="var_005" value="|acute|chronic|exacerbation"] [select name="var_006" value="|Chest Pain|Pulmonary Embolism|Pneumonia|Abdominal Pain|"]. The patient is in need of [checkbox name="var_007" value="|Cardiologist|CATH Lab|Oncologist|Mental Health Services|Nephrology|Dialysis capabilities|Neurology|Obstetrics|Orthopedic care|Pediatrics|Pulomonology|Stroke care|Urology|Surgery Center|Psychiatric|Hematology|Gastroenterology|Ortho|Pain Management|Oncology|Otolaryngologist (ENT)|Ophthalmologist|Infectious Disease Physician|Dermatologist|Mental Health|Other:|"]. The transferring physician requests the patient be transferred with [checkbox name="var_008" value="|Vitals|Medical Supervision|Blood Pressure Monitoring|SpO2|EKG monitoring|12 lead EKG|Oxygen administration|IV Fluids via Gravity|IV Fluids via Pump|IV Medications via Gravity|IV Medications via Pump|IV Medications via Syringe Push|Ventilator|C-Pap|BiPap|Positioning for pain|Support UnStable Fractures|"].
Upon arrival, found a [text name="Var_009" size="3"] lb, [var name="var_002"] year old [select name="var_010" value="|Caucasian|American Indian or Alaska Native|Asian|Black or African American|Native Hawaiian or Other Pacific Islander|Unknown|"]
There are 18 form elements.
Result - Copy and paste this output: