Bronchitis History

History provided by [text]
The patient has had symptoms for [text] days

Pertinent positives include: [checkbox value="cough|chest congestion|shortness of breath|wheezing|productive cough|non-productive cough"]

Sputum is [select value="clear|purulent|blood-tinged"]

Other recent symptoms include:  [checkbox value="sore throat|nasal congestion|earache|headache|myalgias|fever"]
Pertinent negatives include:  [checkbox value="sore throat|nasal congestion|earache|headache|myalgias|fever"]
Past History:
[select value="no|yes"] chronic respiratory problems
[select value="no|yes"] frequent pneumonia
[select value="no|yes"] frequent bronchitis
[select value="no|yes"] asthma
[select value="current|former|exposure to second hand"] tobacco use
[select value="no|yes"] occupational exposure to potentially harmful inhalants
History provided by
The patient has had symptoms for days

Pertinent positives include:

Sputum is

Other recent symptoms include:  
Pertinent negatives include: 
Past History:
chronic respiratory problems
frequent pneumonia
frequent bronchitis
asthma
tobacco use
occupational exposure to potentially harmful inhalants

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.83, 12 form elements, 40 boilerplate words, 2 text boxes, 3 checkboxes, 7 drop downs, 27 total clicks
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