[checkbox name="Behavioral changes" value="dizziness|LOC|Balance problems"][checkbox name="Conussion" value="Slow reaction time|amnesia|sleep disturbance"][checkbox name="field_name" value="headaches|irritability|nausea"][checkbox name="field_name" value="vomiting|light sensativity|balance problems"]

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Sandbox Metrics: Structured Data Index 1, 4 form elements, 4 checkboxes, 12 total clicks
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