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Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
[select name="variable_2" value="Attending to ADLs|Not attending    to ADLs"].
Behavior - general: [select name="variable_3" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_4" value="calm|agitated"].
Behavior - interactivity: [select name="variable_5" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_6" value="eye contact good|eye contact fair|eye contact avoidant"].
Stated mood:[text name="variable_7" default="sample text"]
Mood/Affect - emotional range: [select name="variable_8" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_9" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_10" value="mood is congruent with affect|mood and affect are not congruent"].
Perception - insight: [select name="variable_11" value="normal insight|poor insight"]
Perception - general: [select name="variable_12" value="normal|hallucinations - auditory|hallucinations - auditory, talking to someone not present|hallucinations - visual|hallucinations - visual - looking at something not present|hallucinations - multiple"]
Judgment: [select name="variable_13" value="normal|poor|good"].
Eating disorder thoughts/urgesreported:[select name="variable_14" value="low|moderate|high|"][select name="variable_14"="restriction|purging|denies"].
Suicide:[select name="variable_15" value="denies suicidal ideation|endorsed passive suicidal ideation"].
[select name="variable_16" value="Denies safety concerns"].
Self-harm:[select name="variable_17" value= "denies self-harm    urges|reported self-harm urges"].
IMP:[select name="variable_18" value="compliant|non-compliant"].
Appearance: .
Behavior - general: .
Behavior - stability: .
Behavior - interactivity: .
Behavior - eye contact: .
Stated mood:
Mood/Affect - emotional range: .
Mood/Affect - intensity: .
Mood/Affect - congruence: .
Perception - insight:
Perception - general:
Judgment: .
Eating disorder thoughts/urgesreported:.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.95, 19 form elements, 43 boilerplate words, 1 text boxes, 18 drop downs, 19 total clicks
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