URI URTI HPI

HPI: [comment memo="URI/URTI Upper Respiratory Tract Infection HPI Template"]
[text size="4"]yo [select value="M|F"] with [comment memo="symptoms"][checkbox name="URTIsx" value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|difficulty swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"] for the past [text size="4"] [select value="day(s)|week(s)"][comment memo="duration"]
[conditional field="URTIsx" condition="(URTIsx).is('ear pain')||(URTIsx).is('sinus pain in cheeks and/or forehead')||(URTIsx).is('sore throat')||(URTIsx).is('pain with swallowing')"]-Pain severity: [text size="4"]/10
[/conditional]-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria"][conditional field="Centor" condition="(Centor).is('YES')"]

Modified Centor Score
[select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F
[select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing
[select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes
[select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates
[select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age
Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional]
[comment memo="modifying factors"]
-Therapies tried that have improved symptoms: [text size="50"]
-Therapies tried that have NOT improved symptoms: [text size="50"]
-[comment memo="Additional comments:"][textarea]

Review of Systems: 
[radio value="fever"][radio value="chills"][radio value="body aches"][radio value="chest pain"][radio value="nausea"][radio value="vomiting"][radio value="diarrhea"]
[comment memo="For use in CRDAMC FM Clinic"]
HPI: URI/URTI Upper Respiratory Tract Infection HPI Template
yo with symptoms for the past duration
-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? Choose 'yes' to bring up Centor Criteria
modifying factors
-Therapies tried that have improved symptoms:
-Therapies tried that have NOT improved symptoms:
-Additional comments:

Review of Systems:

For use in CRDAMC FM Clinic

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.73, 32 form elements, 36 boilerplate words, 5 text boxes, 1 text areas, 1 checkboxes, 7 radio buttons, 8 drop downs, 7 comments, 1 calculations, 2 conditionals, 36 total clicks
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