1 patient

Room Number: [text name="variable_1" default=""] Name: [text name="variable_1" default=""] 
Age [text name="variable_1" default=""][checkbox name="variable_3" value="Male |Female "]
HPI / Overnight Events:
[textarea name="variable_47" default=""]

Physical:
Vitals: Temp:[text name="variable_40" default=""] HR:[text name="variable_40" default=""] RR:[text name="variable_40" default=""] BP:[text name="variable_40" default=""]
[checkbox name="Generally" value="Patient is in NAD|Is laying in bed|Seen ambulating|Sitting at bedside|In common area|c/o SOB|c/o pain|no s/s of respiratory distress"]
Lab Results:
Glucose:[text name="variable_32" default=""] Na:[text name="variable_33" default=""] K:[text name="variable_34" default=""]
Cl:[text name="variable_35" default=""] CO2:[text name="variable_36" default=""] AGAP:[text name="variable_37" default=""] 
Ca:[text name="variable_38" default=""] BUN[text name="variable_39" default=""] Cre:[text name="variable_40" default=""] 
WBC:[text name="variable_72" default=""] Hgb:[text name="variable_73" default=""] Plts:[text name="variable_41" default=""]
Hct:[text name="variable_74" default=""] MCV:[text name="variable_41" default=""]

Other Notes: [textarea name="variable_43" default=""]
Room Number: Name:
Age
HPI / Overnight Events:


Physical:
Vitals: Temp: HR: RR: BP:

Lab Results:
Glucose: Na: K:
Cl: CO2: AGAP:
Ca: BUN Cre:
WBC: Hgb: Plts:
Hct: MCV:

Other Notes:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.08, 25 form elements, 31 boilerplate words, 21 text boxes, 2 text areas, 2 checkboxes, 33 total clicks
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