BOP- General Sick call

[text name="variable_1" default="AGE"] year old AIC seen in [text name="variable_2" default="LOCATION    VISIT"]    for    [text name="variable_3" default="Complaint"]:
1.      [text name="variable_3" default="Complaint"]:
-    Onset:[text name="variable_4" default="sample text"][select name="variable_6" value="days|weeks|months"]
-    Location of Sx:    [textarea name="variable_5" default=""]
-    Duration: [text name="variable_7" default=""]
-    Characteristic: [textarea name="variable_8" default=""]
-    Associated Sx:  [textarea name="variable_9" default=""]
-    Aggravting factors: [text name="variable_10" default=""]
-    Relieving factors: [text name="variable_11" default=""]
-    Severity/pain: [textarea name="variable_12" default=""]

otc/non-rx remedies tried: [text name="variable_13" default="sample text"]