ROS Checkbox

GENERAL: [checkbox name="variable_1" value=" + fatigue|No fatigue|+ Wt Gain|No Wt gain|+ Wt Loss|No Wt Loss|+ Fever|No Fever|+ Chills, |No Chills, "][text name="variable_1" default=", "]
EYES: [checkbox name="variable_2" value=" + pain|No pain|+ blurry vision|No blurry vision|+ blindness|No blindness|+ glasses, |No glasses, "][text name="variable_2" default=", "]
ENT: [checkbox name="variable_3" value=" + hearing loss|No hearing loss|+ aides|No aides|+ dentures|No dentures|+ sore throat|No sore throat|+ sore tongue|No sore tongue"][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|+ Claudication (pain lower extremities)|No Claudication (pain lower extremities)"][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|2 LPM|3 LPM"][text name="variable_5" default=", "]
GI: [checkbox name="variable_6" value=" + 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|+ Nocturia|No Nocturia|+ Incontinence|No Incontinence|+ Urine Retention|No Urine Retention|+ foley|No Foley|+ Hx UTI|No Hx UTI"][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|+ Limb Pain|No Limb Pain|+ Myalgias|No Myalgias|+ Walker|No Walker|+ Wheelchair|No Wheelchair|+ Cane|No Cane|+ Independent Gait|No Independent Gait|+ Needs Assist|No Needs Assist|+ Non-ambulatory|+ Ambulatory|+ Self-transfers|No Self-Transfers|+ Bed bound|Not Bed Bound|+ Generalized weakness"][text name="variable_9" default=", "]
NEURO: [checkbox name="variable_10" value=" + Weakness|No Weakness|+ HA|No HA|+ Sz|No Sz|+ Tremors|No Tremors|+ Falls|No Falls|+ Hx Falls|No Hx Falls|+ Neuropathy|No Neuropathy|+ Vertigo|No Vertigo|+ 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|+ Psychosis|No Psychosis"][text name="variable_11" default=", "]
ENDO: [checkbox name="variable_12" value=" + Polydipsia|No Polydipsia|+ Polyuria|No Polyuria|+ Heat Intolerance|No Heat Intolerance"][text name="variable_12" default=", "]
SKIN: [checkbox name="variable_13" value=" + Rash|No Rash|+ Pruritus|No Pruritus|+ Wounds|No Wounds|+ Infection|No Infection"][text name="variable_13" default=", "]