My assessment

Chronic Condition:
[select name="variable_1" value="Hypertension|Chronic Low Back Pain|Type 2 Diabetes| Tobacco Use| GERD| ADHD| Right Knee Pain| Left Knee Pain|Foot Pain| Neck Pain| Cervicalgia| Carpal Tunnel| Anxiety| Depression| Hyperlipidemia| Muscle Spasm of the Back| Lumbar Disc displacement| HIV| Bilateral Knee Pain| Obesity| Primary OA of bilateral knees| COPD| Asthma|"]

Patient reports that the condition is:
[checkbox name="variable_1" value="Stable/ well controlled with current therapy|not well controlled|stable"]

and is 
[checkbox name="variable_1" value="unchanged from last visit|improved from last visit|worse than last visit"]