[select value="Lumbago|Lower Back Pain|Lower Back Spasm"]
[checkbox value="Ibuprofen 400 mg three times a day with food as needed for pain|Naproxen 500 mg three times a day with food as needed for pain|Acetaminophen 650 mg four times daily as needed for pain|Discussed heat and ice massage|Flexeril 10 mg nightly as needed for pain/spasm (sedation side effect discussed)"]
[checkbox value="Discussed postural exercises such as walking/swimming 3 times a week for 40 minutes|Discussed stretching and strengthening exercises and staying active|If no improvement in next week, call or return to clinic for Physical Therapy referral"]
There are 3 form elements.
Result - Copy and paste this output: