Visit Brains

[date name="variable_1" default="04-11-2024"]
Patient    is    a    [text name="variable_1" default=""]    year    old    [select name="variable_1" value="male|female|"]    who    lives    [select name="variable_1" value="alone|with    husband|with    wife|with    family|with    son|with    daughter"][select name="variable_1" value="at    home|in    apartment    unit    on    first    floor|in    apartment    unit    on    second    floor|in    apartment    unit    on    third    floor|in    apartment    unit    on    fourth    floor|in    apartment    unit    on    fifth    floor|in    apartment    unit    on    sixth    floor|in    apartment    unit    on    seventh    floor|in    apartment    unit    on    eighth    floor|in    apartment    unit    on    ninth    floor|in    apartment    unit    on    tenth    floor|in    apartment    unit    on    eleventh    floor|in    apartment    unit    on    twelfth    floor|in    apartment    unit    on    thirtheenth    floor|in    apartment    unit    on    fourteenth    floor|in    apartment    unit    on    fifteenth    floor|in    apartment    unit    on    sixteenth    floor|in a    Board    and    Care    facility"]
[text name="variable_1" default="sample text"][select name="variable_1" value="choice A|choice B|choice C"]