GENERAL: [checkbox name="variable_1" value=" + fatigue|No fatigue|+ Weight Gain|No Weight gain|+ Weight Loss|No Weight Loss|+ Fever|No Fever|+ Chills, |No Chills,|+ Night sweats| No Night Sweats, "][text name="variable_1" default=", "]
EYES: [checkbox name="variable_2" value=" + pain|No pain|+ blurry vision|No blurry vision|+ glasses, |No glasses, "][text name="variable_2" default=", "]
ENT: [checkbox name="variable_3" value=" + hearing loss|No hearing loss|+ Ear Pain| No Ear Pain|+Congestion| No Congestion| + dentures|No dentures|+ sore throat|No sore throat| +Painful Swallowing|No Painful Swallowing| "][text name="variable_3" default=", "]
CARDIAC: [checkbox name="variable_4" value=" + dizziness|No dizziness|+ palpitations|No palpitations|+ pedal edema|No pedal edema|+ PND (Paryoxysmal Nocturnal Dyspnea)|No PND (Paryoxysmal Nocturnal Dyspnea)|+ Syncope|No Syncope|+ Chest Pain|No Chest Pain"][text name="variable_4" default=", "]
RESP: [checkbox name="variable_5" value=" + cough|No cough|+ chronic cough|+ sputum|No sputum|+ SOB|No SOB|+ Wheezing|No Wheezing|+ O2 Use|No O2 use"][text name="variable_5" default=", "]
GI: [checkbox name="variable_6" value=" +Decrease in appetite| No Decrease in appetite| + Pain|No Pain|+ Reflux|No Reflux|+ Anorexia|No Anorexia|+ Dysphagia|No Dysphagia|+ Constipation|No Constipation|+ Diarrhea|No Diarrhea|+ Nausea|No Nausea|+ Vomiting|No Vomiting|+ Bleeding|No Bleeding"][text name="variable_6" default=", "]
GU: [checkbox name="variable_7" value=" + Dysuria|No dysuria|+ Hematuria|No Hematuria|+Urgency| No Urgency| +Frequency| No Frequency| + Nocturia|No Nocturia|+ Incontinence|No Incontinence"][text name="variable_7" default=", "]
HEME: [checkbox name="variable_8" value=" + Easy Bruising|No Easy Bruising|+ Bleeding|No Bleeding|+ Lymphadenopathy|No Lymphadenopathy"][text name="variable_8" default=", "]
M/S: [checkbox name="variable_9" value=" + Arthralgias|No Arthralgias|+ Back Pain|No Back Pain|+ Myalgias|No Myalgias|Ambulation status: "][text name="variable_9" default=", "]
NEURO: [checkbox name="variable_10" value=" + Weakness|No Weakness|+ Headache|No Headache|+ Tremors|No Tremors|+ Falls|No Falls|+ Neuropathy|No Neuropathy|+ Poor Balance|No Poor Balance"][text name="variable_10" default=", "]
PSYCH: [checkbox name="variable_11" value=" + Anxiety|No Anxiety|+ Depression|No Depression|+ Memory Loss|No Memory Loss|+ Insomnia|No Insomnia|+ Hypersomnolence|No Hypersomnolence"][text name="variable_11" default=", "]
ENDO: [checkbox name="variable_12" value=" + Polydipsia|No Polydipsia|+ Polyuria|No Polyuria|+Polyphagia| No polyphagia| + Heat Intolerance|No Heat Intolerance | +Cold Intolerance | No Cold Intolerance "][text name="variable_12" default=", "]
SKIN: [checkbox name="variable_13" value=" + Rash|No Rash|+ Pruritus|No Pruritus|+ Wounds|No Wounds"][text name="variable_13" default=", "]

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 26 form elements, 14 boilerplate words, 13 text boxes, 13 checkboxes, 150 total clicks
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