Neurology
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Prenatal
[select name="v1" value="no=0|yes=1"]<--Family history [text name="fh" size="10"]
Natal
[select name="v2" value="no=0|yes=1"]<--Perinatal birth complications [text name="pbc" size="10"]
[select name="v3" value="no=0|yes=1"]<--Intellectual disability [text name="pbc" size="10"]
Post Natal
[select name="v4" value="no=0|yes=1"]<--Substance abuse [text name="sa" size="10"]
[select name="v5" value="no=0|yes=1"]<--Drug causing seizures [text name="dcs" size="10"]
[select name="v6" value="no=0|yes=1"]<--Fever [text name="f" size="10"]
[select name="v7" value="no=0|yes=1"]<--Hypoxia [text name="o2" size="10"]
[select name="v8" value="no=0|yes=1"]<--SLE [text name="sle" size="10"]
[select name="v9" value="no=0|yes=1"]<--Hypoglycemia [text name="glu" size="10"]
[select name="v10" value="no=0|yes=1"]<--Organ failures [text name="of" size="10"]
[select name="v11" value="no=0|yes=1"]<--Dementia [text name="dem" size="10"]
[select name="v12" value="no=0|yes=1"]<--Trauma - Head [text name="hi" size="10"]
[select name="v13" value="no=0|yes=1"]<--Tumor [text name="tum" size="10"]
[select name="v14" value="no=0|yes=1"]<--Stroke history [text name="str" size="10"]
[select name="v15" value="no=0|yes=1"]<--Structural - Hydrocephalus [text name="nph" size="10"]
[select name="v16" value="no=0|yes=1"]<--Insomnia [text name="ins" size="10"]
* no may also mean not known

[calc value="(v1)+(v2)+(v3)+(v4)+(v5)+(v6)+(v7)+(v8)+(v9)+(v10)+(v11)+(v12)+(v13)+(v14)+(v15)+(v16)"]<-- no of risk factors for epilepsy present
Prenatal
<--Family history
Natal
<--Perinatal birth complications
<--Intellectual disability
Post Natal
<--Substance abuse
<--Drug causing seizures
<--Fever
<--Hypoxia
<--SLE
<--Hypoglycemia
<--Organ failures
<--Dementia
<--Trauma - Head
<--Tumor
<--Stroke history
<--Structural - Hydrocephalus
<--Insomnia
* no may also mean not known

(v1)+(v2)+(v3)+(v4)+(v5)+(v6)+(v7)+(v8)+(v9)+(v10)+(v11)+(v12)+(v13)+(v14)+(v15)+(v16)<-- no of risk factors for epilepsy present

Result - Copy and paste this output: