chest pain

[checkbox memo="Chest Pain" name="co_cp" value=""][conditional field="co_cp" condition="(co_cp).is('')"]
Onset [select name="co_onset" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31"] [select name="co_time" value="Minutes|Hours|Days|Weeks|Months|Years"]
Pain rating at onset [select name="co_scale_1" value="0|1|2|3|4|5|6|7|8|9|10]
Pain rating at Max [select name="co_scale_2" value="0|1|2|3|4|5|6|7|8|9|10]
Pain rating now [select name="co_scale_3" value="0|1|2|3|4|5|6|7|8|9|10]
Onset while: [select name="co_cp_doing" value="|Woke up from sleeping|Was at rest, not sleeping (sitting around, watching TV etc)|With exertion (exercise, physical work, etc)"]
Onset rate: [select name="co_cp_onset2" value="Un sure|Rapidly|Slowly|"]
[select name="co_cp_onset3" value="Constant|Intermittent"]
Any recent Injury or medical event that could be contributing? [select name="co_cp_contrib1" value="no|yes"]
Location [checkbox name="co_cp_loc" value="Med Chest|Right Lateral Chest|Left Lateral Chest|Sub-Sternum area|Right shoulder|Left chest|"]
[checkbox memo="Radiates" name="co_cp_rad" value=""][conditional field="co_cp_rad" condition="(co_cp_rad).is('')"]
[checkbox name="co_cp_rads" value="Med Chest|Right Lateral Chest|Left Lateral Chest|Sub-Sternum area|Right shoulder|Left chest|Back - Upper|Back - Lower|Abdomen|Right Arm|Left Arm"]
[/conditional] 

Provocations [checkbox name="co_cp_provoke" value="Inspiration|Expiration|Exertion - Light (moving around, walking)|Exertion - Heavy (exercise)|When coughing|"]
Alleviations [checkbox name="co_cp_alleviate" value="Not Moving|Particular positioning (sitting up, etc)"]
[select name="co_cp_keyq1" value="no|yes|not sure"]


[checkbox memo="Has the patient had pain like this before?" name="co_cp_before" value=""][conditional field="co_cp_before" condition="(co_cp_before).is('')"]
How llong ago? [select name="co_bef" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31"] [select name="co_bef_time" value="Minutes|Hours|Days|Weeks|Months|Years"]

[checkbox memo="Does the patient have a cardiaologist?" name="co_cp__doc" value=""][conditional field="co_cp_doc" condition="(co_cp_doc).is('')"]
When did you see them last? [select name="co_doc_t1 value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31"] [select name="co_doc_t2" value="Minutes|Hours|Days|Weeks|Months|Years"]

[/conditional] 

[/conditional] 



Pitfalls:
[select value="no|YES"] <-- unilateral leg swelling
[select value="no|YES"] <-- recent prolonged travel
[select value="no|YES"] <--recent trauma
[select value="no|YES"] <--hypercoagulable state
[select value="no|YES"] <--hormonal therapy

[/conditional]