[select value="Vaginitis|Bacterial vaginosis|Candida vaginitis|Gardnerella vaginitis|Trichomonas vaginitis|Herpes vaginitis|Cervicitis|PID"]
[checkbox value="pelvic ultrasound|CBC|pregnancy test|sed rate|none"]
[checkbox value="observe|over the counter antifungal preparation|diflucan orally|metronidazole orally|metronidazole vaginally|clindamycin vaginally|azithromycin orally|doxycycline orally|other treatment"]
[checkbox value="Follow up as needed|Follow up if worsening|Follow up in 1-2 weeks|Follow up for test of cure|Side effects/interactions of medications|Cautioned patient to consume no alcohol during course of treatment and including 72 hours after completion of treatment"]
There are 5 form elements.
Result - Copy and paste this output: