CTI

I certify that  [text name="variable_1" default="sample text"]is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course.
KPS 
[select name="variable_1" value="choice A|choice B|choice C"]
PPS 
[select name="variable_1" value="choice A|choice B|choice C"]
FAST 
[select name="variable_1" value="choice A|choice B|choice C"]
NYHA IV
Maximum dependence on 
[select name="variable_1" value="4/6|5/6|6/6"]

[text name="variable_1" default="sample text"] is year old 
[select name="variable_1" value="choice A|choice B|choice C"] with a diagnosis 
[text name="variable_1" default="sample text"]
com-morbidities
[text name="variable_1" default="sample text"]
Patient no longer wants to pursue aggressive treatment and states 
[select name="variable_1" value="choice A|choice B|choice C"] wants comfort measures only. 

Increased dyspnea and pain over past two weeks. 
Is now oxygen dependent with 2LNC 
and requires morphine every six hours for  pain and shortness of breath
I certify that is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course.
KPS

PPS

FAST

NYHA IV
Maximum dependence on


is year old
with a diagnosis

com-morbidities

Patient no longer wants to pursue aggressive treatment and states
wants comfort measures only.

Increased dyspnea and pain over past two weeks.
Is now oxygen dependent with 2LNC
and requires morphine every six hours for pain and shortness of breath

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.6, 10 form elements, 78 boilerplate words, 4 text boxes, 6 drop downs, 10 total clicks
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