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Patient is being seen for [checkbox name="variable_1" value="||||"]
[select name="variable_1" value="|acute onset|gradual onset"]
Symptoms lasting x [select name="variable_2" value="1|2|3|4|5|6|7"] Days

[text name="variable_1" default=""]

Associated Symptoms:
[checklist name="variable_2" value=" |||||||"]

Treatment:
[checkbox name="variable_3" value=" ||"]

[textarea name="variable_1" default=""]
Patient is being seen for

Symptoms lasting x Days



Associated Symptoms:


Treatment:


Result - Copy and paste this output: