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[checkbox memo="Chronic Obstructive Pulmonary Disease" name="copd" value=""][conditional field="copd" condition="(copd).is('')"][select name="prob_copd_status" value="|Acute|Chronic|Un-controlled|Exacerbation"][select name="prob_copd" value="Chronic obstructive pulmonary disease, unspecified J44.9=1|Chronic obstructive pulmonary disease with (acute) exacerbation J44.2=2|Chronic obstructive pulmonary disease with acute lower respiratory infection J44.0=3"][/conditional]
[comment memo="------------------------Cardiac Compaints-----------------------------"]
[checkbox memo="Chest Pain" name="chest_pain" value=""]
[conditional field="chest_pain" condition="(chest_pain).is('')"]
[select name="prob_chest_pain_status" value="|Acute|Chronic|Un-controlled|Exacerbation"]
[select name="prob_chest_pain" value="Chest pain, unspecified R07.9 (Cardiac)=1|Other chest pain R07.89 (Non-Cardiac/Respiratory)=2|Chest pain on breathing R07.1=3"]

[/conditional]

[checkbox memo="Atrial Fiburlation" name="afib" value=""]
[conditional field="afib" condition="(afib).is('')"]
[select name="prob_afib_status" value="|Acute|Chronic|Un-controlled|Exacerbation"]
[select name="prob_afib" value="Chronic atrial fibrillation I48.2=1|Unspecified atrial fibrillationI48.91=2"]

[/conditional]
Chronic Obstructive Pulmonary Disease
------------------------Cardiac Compaints-----------------------------
Chest Pain


Atrial Fiburlation
Result - Copy and paste this output: