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[text name="variable_1" default="NAME"] is a pleasant [text name="variable_2" default="AGE"] [select name="variable_1" value="day|month|year"] old [select name="variable_2" value="male|female"] who presents today with [select name="variable_3" value="his|her"] [checkbox name="variable_1" value="mother|father|step-mother|step-father|grandmother |grandfather|family friend|guardian|sibling|siblings|other"].

[select name="variable_4" value="He|She|Mother|Father| Step-Mother|Step-Father|Grandmother|Grandfather|Family Friend|Guardian|"] complains of [checkbox name="variable_2" value="cough|nasal congestion|sore throat|fever|nausea| vomiting|diarrhea|headache|stomach ache|subjective fever (did not measure)"] starting [text name="variable_3" default="LENGTH"]days ago. [select name="variable_5" value="He|She|Mother|Father| Step-Mother|Step-Father|Grandmother|Grandfather|Family Friend|Guardian|"]reports
is a pleasant old who presents today with .

complains of starting days ago. reports

Result - Copy and paste this output: