physical_sample

chief_complaints::textarea

<h3>past surgical history</h3>
+surgical history::checkbox_group::cholecystectomy::tonsillectomy::apendectomy::hernia
<h4>other</h4>
surgical history other::textfield

<h3>past medical history</h3>
+medical history::scrolling_list_multiples::asthma::diabetes::hypertension::GERD
<h4>other</h4>
medical history other::textfield

<h2>Allergies</h2>
+allergies::checkbox_group::penicillin::sulfa::iodine
<h4>other</h4>
allergies other::textfield

<h2>Social History</h2>
<h3>smoking</h3>
smoke history::radio_group::non-smoker::smoker
<h3>alcohol</h3>
etoh history::scrolling_list::none::occasional::daily::heavy use
<h3>last mammogram</h3>
last mammogram::date