AP Chart Review PREs

AP Chart Review PREs
Job Title: [text name="job_title" default=""]
Work Group: [select name="work_group" value="YYY|NNN|NYN|YYN"]
DOH:[date name="DOH" default=""] [text name="DOH_text" default=""]

Medication: [select name="medication" value="none|yes|"]
[text name="medication" default=""]
Allergies: [select name="allergies" value="none|yes|"]
[text name="allergies" default=""]
Health Hx: [select name="health_hx" value="reviewed, cleared|yes|"]
[text name="health_hx" default=""]
Respiratory Questionnaire: [select name="fit_test" value="reviewed, cleared|"]
[text name="fit_test" default=""]
ARCH questionnaire: [select name="ARCH" value="reviewed, cleared|N/A"]
[text name="ARCH" default=""]
Immunizations:
[checklist name="immunizations" value="COVIDx3|Flu UTD|TDAP UTD|PPDx2|IGRA/Quantiferon UTD|HepBx3|HepB titer|MMRx2|VZVx2|MMR titer|VZV titer"]
[text name="immunizations" default=""]

Needs: 
[select name="needs" value="PPD x2 or IGRA w/in 90 days of hire + fit test|"]
[text name="needs" default=""]