Rash Rod

Patient is being seen for [checkbox name="variable_1" value="rash|itching|skin concern"]
Locations: [text name="variable_1" default=""]
Symptoms lasting x [select name="variable_1" value="1|2|3|4|5|6|7|8|9|"] days.
Onset [select name="variable_2" value="Gradual|Acute|Chronic"]

Associated Symptoms:
[checklist name="variable_2" value="fever|sore throat|upset stomach|itching|mouth sores|painfull rash|conjunctivitis|genital symptoms|decrease appetite|dry eyes|Nausea or Vomiting|headache|runny nose"]

Pertinent hx:
[checklist name ="variable_3" value=" Recent new medications|Recent travel|Recent exposure to known allergen|Uptodate with immunizations"]
[text name="variable_6" default=""]

[checkbox name="variable_3" value="Bendaryl |Sterioid cream|Antibiotic cream|No treatment"]
[text name="variable_3" default=""]

[textarea name="variable_1" default=""]
Patient is being seen for
Symptoms lasting x days.

Associated Symptoms:

Pertinent hx:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.6, 10 form elements, 16 boilerplate words, 3 text boxes, 1 text areas, 2 checkboxes, 2 check lists, 2 drop downs, 30 total clicks
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