Acute Resp DH

Complains    of    cough x [text] [select name="variable_3" value="days|weeks|months"].
Cough is [checkbox name="variable_5" value="dry|Dry to productive|sputum clear|sputum purulent|harsh and barking quality|post-tussive emesis"]
Haemoptysis    is    [select value="absent|PRESENT"]
Frequency of    cough    is [select value="infrequent|intermittent|constant"].
Severity is [select value="minimal|moderate|severe"].
[select value="Little    or    no    sputum|Moderate    amount    of    sputum|Large    volume    of    sputum    daily"].
Fever [select value="is not present|is present"][text name="variable_1" default=""].
[select value="No    dyspnoea|Dyspnoea    on    exertion|Dyspnoea    at    rest"].
[select value="No    pleuritic    chest    pain|Pleuritic    chest    pain|Non-pleuritic    chest    pain"].
[select value="No    feeling    of    chest    tightness    or    wheeze|Feels    tight    or    wheezy"].
[select value="Sleeping    fairly    normally|Sleep    is    disturbed|Great    difficulty    sleeping"].
[select value="No    night    sweats|Clammy    at    night|Drenching    night    sweats"].
Medications/remedies that have been tried are    [checkbox value="SABA    inhaler|Paracetamol|Ibuprofen|Exputex|Other    cough    bottle|Antibiotics"] [textarea name="variable_6" default=""].

Patient has [select value="no known|known"] sick contacts at home, school, or work.

Other symptoms: [checkbox value="sore throat|preceding URTI|nasal congestion|earache|PND|heartburn|headache|myalgias"]

Prior    history of respiratory problems:  [checkbox name="pulmhx" value="No significant    respiratory problems|frequent pneumonia|frequent bronchitis|asthma|COPD|Bronchiectasis|other"][conditional field="pulmhx" condition="(pulmhx).is('other')"][text size=72 memo="<--describe other"][/conditional]

Tobacco: [checkbox name="tobacco" value="Patient is not a smoker|Patient is a current smoker|Patient a former smoker"][conditional field="tobacco" condition="(tobacco).is('Patient is a current or former smoker')"] [text size=72 memo="<--smoking details (optional)"][/conditional]

PE/DVT risk factors/ other risk factors

[checklist name="variable_4" value="chest pain|dyspnoea|lower limb oedema|haemoptysis | recent travel|Pregnancy|Oestrogen    therapy|Active    malignancy|Recent    immobilisation|Prior    history    of PE/DVT|Family    history    of PE/DVT"]

Drug    Allergy:
[checkbox    name="NKDA" value="No    known    drug    allergies|Allergic    to    Penicillin|Allergic    to    tetracycline|Allergic    to    Sulphamethoxazole|Other"][conditional field="NKDA" condition="(NKDA).is('Other')"][text size=72 memo="<--describe other"][/conditional]
Complains of cough x .
Cough is
Haemoptysis is
Frequency of cough is .
Severity is .
Fever .
Medications/remedies that have been tried are

Patient has sick contacts at home, school, or work.

Other symptoms:

Prior history of respiratory problems:


PE/DVT risk factors/ other risk factors

Drug Allergy:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.76, 28 form elements, 48 boilerplate words, 5 text boxes, 1 text areas, 6 checkboxes, 1 check lists, 12 drop downs, 3 conditionals, 64 total clicks
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