Radiology Criteria

[checkbox name="studytype" value="CT|MRI|Ultrasound"]

[conditional field="studytype" condition="(studytype).is('CT')"]Body Part:[checkbox name="ctbody" value="Head|Facial|Neck|Cervical|Chest|Abdomen and Pelvis|Extremity"][/conditional][conditional field="studytype" condition="(studytype).is('MRI')"]Body Part:[checkbox name="mribody" value="Head|Facial|Neck|Cervical|Chest|Abdomen and Pelvis|Extremity"][/conditional][conditional field="studytype" condition="(studytype).is('Ultrasound')"]Body Part:[checkbox name="mribody" value="Head|Facial|Neck|Cervical|Chest|Abdomen and Pelvis|Extremity"][/conditional]

[conditional field="ctbody" condition="(ctbody).is('Head')"] Order:[checkbox name="cthead" value="CT Head without Contrast|CT Head with Contrast|CT Head with AND without Contrast"][/conditional]

[conditional field="cthead" condition="(cthead).is('CT Head without Contrast')"][comment memo="R41.0 Disorientation, unspecified
R41.82 Altered Mental Status, Unspecified
Z79.01 Long term (current) use of anticoagulants
I16.1 Hypertensive emergency
F05.0 Delirium due to known physiological condition
G45.9 TIA

G81.90 affecting unspecified side
G81.91 affecting right dominant side
G81.92 affecting left dominant side
G81.93 affecting right nondominant side
G81.94 affecting left nondominant side
R56.9 Unspecified convulsions

Vision Loss
H53.131 Sudden visual loss, right eye
H53.132 Sudden visual loss, left eye
H53.133 Sudden visual loss, bilateral
H53.139 Sudden visual loss, unspecified eye

M26.10 Unspecified anomaly of jaw-cranial base relationship
M26.11 Maxillary asymmetry
M26.12 Other jaw asymmetry
M26.19 Other specified anomalies of jaw-cranial base relationship"][/conditional]

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 11 form elements, 5 checkboxes, 1 comments, 5 conditionals, 27 total clicks
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