3 chief_complaints::textarea
5 <h3>past surgical history</h3>
6 +surgical history::checkbox_group::cholecystectomy::tonsillectomy::apendectomy
8 surgical history other::textfield
10 <h3>past surgical history</h3>
11 +medical history::scrolling_list_multiples::asthma::diabetes::hypertension
13 medical history other::textfield
16 +allergies::checkbox_group::penicillin::sulfa::iodine
18 allergies other::textfield
20 <h2>Social History</h2>
22 smoke history::radio_group::non-smoker::smoker
24 etoh history::scrolling_list::none::occasional::daily::heavy use