Category,Question,Base Question (Reference),Sub Question (Reference),SubQuestion,type,options
"Medical History, Family history",High blood pressure,,,,radio,"yes,no"
"Medical History, Family history",Heart attack,,,,radio,"yes,no"
"Medical History, Family history",High cholesterol,,,,radio,"yes,no"
"Medical History, Family history",Stroke/TIA,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Atrial Fib/Arrhythmia ,,,,radio,"yes,no"
"Medical History, Family history",PFO/ Hole in Heart,,,,radio,"yes,no"
"Medical History, Family history",Cancer,,,,radio,"yes,no"
"Medical History, Family history",Coagulopathy/Clotting disorder,,,,radio,"yes,no"
"Medical History, Family history",Diabetes ,,,,radio,"yes,no"
"Medical History, Family history",Kidney disease ,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Thyroid disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Do you drink alcohol?,,,,radio,"yes,no"
"Medical History, Family history",Current everyday,,,,radio,"yes,no"
"Medical History, Family history",Current someday,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history",Beer/Wine/Liquor How many per week?,,,,text,
"Medical History, Family history",Do you use recreational Drugs?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history,Neurology",Have you ever used tobacco?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history",How many packs per day do you or did you smoke?,,,,radio,"< ½, ½ ,1,1 ½,2,2 1/2,3"
"Medical History, Family history",Smoking,,,,radio,"yes,no"
"Medical History, Family history",Angina,,,,radio,"yes,no"
"Medical History, Family history",Stent placement,,,,radio,"yes,no"
"Medical History, Family history",Bypass surgery,,,,radio,"yes,no"
"Medical History, Family history",Pacemaker implant,,,,radio,"yes,no"
"Medical History, Family history",Stroke,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Mini-stroke (TIA),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Carotid surgery,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Aortic aneurysm,,,,radio,"yes,no"
"Medical History, Family history",Fast heart rate,,,,radio,"yes,no"
"Medical History, Family history",Sudden death,,,,radio,"yes,no"
"Medical History, Family history",Pulmonary embolism,,,,radio,"yes,no"
"Medical History, Family history",COPD (lung disease),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Osteoporosis,,,,radio,"yes,no"
"Medical History, Family history",Mental illness,,,,radio,"yes,no"
"Medical History, Family history",Congestive heart failure,,,,radio,"yes,no"
"Medical History, Family history",Coronary artery disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology,Urology",Depression,,,,radio,"yes,no"
"Medical History, Family history",Diverticulitis,,,,radio,"yes,no"
"Medical History, Family history",GERD (heartburn),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Glaucoma,,,,radio,"yes,no"
"Medical History, Family history",Headaches,,,,radio,"yes,no"
"Medical History, Family history",Heart murmur,,,,radio,"yes,no"
"Medical History, Family history,Neurology,Urology",HIV/AIDS,,,,radio,"yes,no"
"Medical History, Family history",Hyperlipidemia (high cholesterol),,,,radio,"yes,no"
"Medical History, Family history",Hypertension (high blood pressure),,,,radio,"yes,no"
"Medical History, Family history",Hypothyroidism,,,,radio,"yes,no"
"Medical History, Family history",Irregular menses,,,,radio,"yes,no"
"Medical History, Family history",Kidney disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Liver disease,,,,radio,"yes,no"
"Medical History, Family history",Menorrhagia,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Myocardial infarction (heart attack),,,,radio,"yes,no"
"Medical History, Family history",Nerve/muscle disease,,,,radio,"yes,no"
"Medical History, Family history",Osteoporosis,,,,radio,"yes,no"
"Medical History, Family history,Urology",Seizures,,,,radio,"yes,no"
"Medical History, Family history",Sickle cell anemia,,,,radio,"yes,no"
"Medical History, Family history",Sleep apnea,,,,radio,"yes,no"
"Medical History, Family history",Substance abuse,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Tuberculosis,,,,radio,"yes,no"
"Medical History, Family history",Ulcers,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Appendectomy,,,,radio,"yes,no"
"Medical History, Family history",Bariatric surgery,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Brain surgery,,,,radio,"yes,no"
"Medical History, Family history",Breast surgery,,,,radio,"yes,no"
"Medical History, Family history",CABG (bypass),,,,radio,"yes,no"
"Medical History, Family history",Cesarean section,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Cholecystectomy (gall bladder removal),,,,radio,"yes,no"
"Medical History, Family history",Colon surgery,,,,radio,"yes,no"
"Medical History, Family history",Cosmetic surgery,,,,radio,"yes,no"
"Medical History, Family history",Eye surgery,,,,radio,"yes,no"
"Medical History, Family history",Fracture surgery,,,,radio,"yes,no"
"Medical History, Family history",Hernia repair,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Hysterectomy (ovaries removed),,,,radio,"yes,no"
"Medical History, Family history",Hysterectomy (ovaries remain),,,,radio,"yes,no"
"Medical History, Family history",Joint replacement,,,,radio,"yes,no"
"Medical History, Family history",Prostate surgery,,,,radio,"yes,no"
"Medical History, Family history",Small intestine surgery,,,,radio,"yes,no"
"Medical History, Family history",Spine surgery,,,,radio,"yes,no"
"Medical History, Family history",Tubal ligation (tubes tied),,,,radio,"yes,no"
"Medical History, Family history",Valve replacement,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Peripheral Neuropathy,,,,checkbox,
"Medical History, Family history",Vasectomy,,,,radio,"yes,no"
"Medical History,Urology",Do you ever drink alcohol?,,,,radio,"Yes – if yes, complete all alcohol related questions,No – if no, skip to next section"
Medical History,,,,Please indicate the quantity per week of each,radio,"yes,no"
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Glasses of wine,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Can/bottles of beer,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Shots of liquor,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Drinks containing .5 oz of alcohol,text,
Medical History,Have people ever felt like you should cut down on drinking?,,,,radio,"yes,no"
Medical History,Have people annoyed you by criticizing your drinking?,,,,radio,"yes,no"
Medical History,Have you ever felt guilty about your drinking?,,,,radio,"yes,no"
Medical History,"Have you ever had an ""eye-opener"" (an alcoholic drink first thing in the morning) to help you feel better?",,,,radio,"yes,no"
Medical History,Drugs and tobacco,,,Do you use drugs?,radio,"yes,no"
Medical History,,,,"If you use drugs, how many times per week?",text,
Medical History,,,,What type(s) of drugs do you use? ,text,
Medical History,Check one of the following about smoking tobacco,,,,radio,"Never smoked,Exposed to second hand smoke,Former smoker,Smoke some days,Smoke everyday"
Medical History,"If you smoked or used to smoke, how many packs do or did you smoke per day?",,,,text,
Medical History,How many years did you smoke / have you smoked?,,,,text,
Medical History,"If you quit smoking, when did you quit?",,,,text,
"Medical History,Neurology",Check one of the following about smokeless tobacco,,,,radio,"Never usedm,Former user,Current user"
Medical History,"If you quit smokeless tobacco, when did you quit?",,,,text,
Medical History,Are you ready to quit smoking or using smokeless tobacco?,,,,text,
Medical History,Do you use e-cigarettes?,,,,radio,"No,Used in the past,Not presently,Occasionally,Daily"
"Medical History,Urology",Sexual activity,,,,,
Medical History,,Sexual activity,,Are you sexually active?,radio,"Yes,No,Not currently"
"Medical History,Urology",,Sexual activity,Are you sexually active?,"If yes, are your partner(s):",radio,"Male,Female,Both"
"Medical History,Urology",Type of birth control / protection (check all that you use):,,,,checkbox,"Not having sex (abstinence),Condom,Injection,IUD (intrauterine device),Oral contraceptives (Pill),Partner vasectomy,Patch,Post-Menopausal,Vasectomy,None,Other (specify):"
Medical History,Do you have a new sexual partner?,,,,text,
"Medical History,Oncology","On average, how many minutes do you engage in exercise at this level?",,,,radio,"0 min,10 min,20 min,30 min,40 min,50 min,60 min,70 min,80 min,90 min,100 min,110 min,120 min,130 min,140 min,150+ min"
"Medical History,Oncology","On average, how many days per week do you engage in moderate to strenuous exercise?",,,,radio,"1 day,2 days,3 days,4 days,5 days,6 days,7 days"
Medical History,,,,,radio,"yes,no"
"Medical History,Neurology",Tonsillectomy and Adenoidectomy,,,,radio,"yes,no"
Medical History,Marital status,,,,radio,"Divorced,Legally separated,Married,Significant other
Single,Widow,Unknown"
"Medical History, Family history",Leg-vascular surgery,,,,radio,"yes,no"
Medical History,Doctor Intake Request,,,,radio,"yes,no"
Medical History,,Doctor Intake Request,,What aspects of hormone replacement therapy (HRT) intrigue you?,text,
Medical History,,Doctor Intake Request,,Is your objective with the program to achieve weight loss?,radio,"yes,no"
Medical History,,Doctor Intake Request,,What is your assigned sex at birth?,,"male,female"
Medical History,,Doctor Intake Request,,"Have you undergone a comprehensive physical examination by a medical professional within the past three years, which included assessments of vital signs such as weight, blood pressure, and heart rate?",radio,"yes,no"
Medical History,,Doctor Intake Request,,"Did you experience any medical issues? If so, could you please elaborate?",radio,"yes,no"
Medical History,,Doctor Intake Request,,Have you ever received a diagnosis of prostate cancer?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Have you been prescribed any hormone treatments currently or in the past?,radio,"Thyroid Medication,Testosterone Treatment,Estrogen Blocker,HGH,Ipamoreline,Colomipheine,HCG,Other,None"
Medical History,,Doctor Intake Request,,"Are you currently using or have you used any over-the-counter or prescription medications, excluding hormone treatments? (Please note that your responses will be cross-checked against prescription and insurance records. Failure to disclose current prescriptions and/or medical conditions may result in disapproval for your safety.)",radio,"yes,no"
Medical History,,Doctor Intake Request,,Do you have any allergies to medications?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Do you intend to have children at some point in the future?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Is your partner currently pregnant or breastfeeding?,radio,"yes,no,Not Applicable"
"Medical History,Neurology",,Doctor Intake Request,,Does your family have a history of any of the following disorders?,radio,"Drug Alcohol,Cancer,Heart Disease,Thyroid Disease,Low Testosterone,None"
Medical History,,Doctor Intake Request,,Are you currently experiencing any erectile dysfunction (ED) issues?,radio,"Never,Almost Never,Occasionally,Almost Always,Always"
Medical History,,Doctor Intake Request,,"Have you ever been diagnosed with thyroid disorders such as hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), Hashimoto's Disease, or Graves' Disease?",radio,"yes,no"
Medical History,How many years did you or have you smoked?,,,,radio,
"Medical History, Family history",Heart Disease,,,,text,
"Medical History, Family history,Neurology",Bleeding Disorder,,,,text,
"Medical History, Family history,Neurology",High Blood Pressure,,,,text,
"Medical History, Family history,Neurology",Blood Clots,,,,text,
"Medical History, Family history",High Cholesterol,,,,text,
"Medical History, Family history,Neurology",Cancer type and stroke,,,,text,
"Medical History, Family history,Neurology",Diabetes  ,,,,text,
Medical History,Do you have any known Allergies to Medications?,,,,checkbox,
Medical History,,Do you have any known Allergies to Medications?,,,checkbox,
Medical History,,Do you have any known Allergies to Medications?,,Iodine,radio,"yes,no"
Medical History,,Do you have any known Allergies to Medications?,,Latex?,radio,"yes,no"
Medical History,,Do you have any known Allergies to Medications?,"Latex?,Iodine?",Reaction,text,
Medical History,,Do you have any known Allergies to Medications?,,Others?,radio,"yes,no"
Medical History,,,Others?,Please list Medication and Reaction,text,
Medical History,What is your current weight,,,,text,
Medical History,What is your current height,,,,radio,"yes,no"
Medical History,,What is your current height,,Feet,text,
Medical History,,What is your current height,,inches,text,
Medical History,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,,,checkbox,
Medical History,,,,Plavix/Clopidogrel:,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Coumadin/Warfarin:,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Aspirin,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Please list the Provider that is monitoring any of the above medications:,text,
Medical History,Review of Systems,,,,radio,"yes,no"
Medical History,,Review of Systems,,Constitutional,radio,"yes,no"
"Medical History,Oncology,Neurology",,Review of Systems,Constitutional,Fatigue/Drenching Night Sweats,checkbox,
"Medical History,Neurology",,Review of Systems,Constitutional,Fever/Chills,checkbox,
Medical History,,Review of Systems,Constitutional,General health excellent/Poor,checkbox,
"Medical History,Oncology",,Review of Systems,Constitutional,Unexplained weight loss/Gain,checkbox,
Medical History,,Review of Systems,,Respiratory,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Respiratory,Asthma/ Anesthetic problems,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,COPD/Pneumonia/Emphysema,checkbox,
"Medical History,Oncology",,Review of Systems,Respiratory,Coughing/coughing up blood,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,Hoarsness/Obstructive Sleep Apnea,checkbox,
Medical History,,Review of Systems,Respiratory,"Oxygen Dependent LPM  	",checkbox,
"Medical History,Oncology",,Review of Systems,Respiratory,Shortness of Breath with Exertion,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,Shortness of breath /Wheezing,checkbox,
Medical History,,Review of Systems,Respiratory,Tuberculosis or exposure,checkbox,
Medical History,,Review of Systems,,Neurological,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Neurological,Migraines/Headache/Vertigo,checkbox,
Medical History,,Review of Systems,Neurological,Temporary/Paralysis Arm/Leg/Face,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Tingling/Numbness,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Speech difficulties/Seizures,checkbox,
Medical History,,Review of Systems,,Eyes,radio,"yes,no"
"Medical History,Oncology",,Review of Systems,Eyes,Blurry vision/Double vision,checkbox,
Medical History,,Review of Systems,Eyes,Cataracts/ Macular degeneration,checkbox,
Medical History,,Review of Systems,Eyes,Glasses/Contacts/Blindness,checkbox,
Medical History,,Review of Systems,Eyes,Glaucoma/Retinopathy,checkbox,
Medical History,,Review of Systems,Eyes,Partial loss of vision/blind spots,checkbox,
"Medical History,Urology",,Review of Systems,,Gastrointestinal,radio,"yes,no"
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Abdominal pain/Blood in stool,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Black or Tarry stool,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Bloating/Diarrhea/Constipation,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Loss of appetite/Heartburn,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Nausea/Vomiting,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Ulcer disease/Pain after eating,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Vomited blood,checkbox,
Medical History,,Review of Systems,,Endocrine,radio,"yes,no"
"Medical History,Urology",,Review of Systems,Endocrine,Cold/Heat intolerance,checkbox,
"Medical History,Urology",,Review of Systems,Endocrine,History of drug resistant infection,checkbox,
Medical History,,Review of Systems,,Ears/Nose/Mouth/Throat,radio,"yes,no"
Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Dentures/Difficulty swallowing,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Hearing Loss/ringing in ears,checkbox,
"Medical History,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Prolonged Nose bleeds,checkbox,
Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Voice change,checkbox,
Medical History,,Review of Systems,,Psychiatric,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Psychiatric,Anxiety/Depression,checkbox,
Medical History,,Review of Systems,Psychiatric,Confusion/Memory loss,checkbox,
Medical History,,Review of Systems,Psychiatric,Difficulty sleeping,checkbox,
Medical History,,Review of Systems,,Cardiovascular,radio,"yes,no"
Medical History,,Review of Systems,Cardiovascular,Ankle Swelling /Varicosities,checkbox,
Medical History,,Review of Systems,Cardiovascular,Calf pain with/without exercise,checkbox,
"Medical History,Oncology",,Review of Systems,Cardiovascular,Chest pain with exertion/Exercise,checkbox,
Medical History,,Review of Systems,Cardiovascular,Chest pain/ Heart murmur,checkbox,
Medical History,,Review of Systems,Cardiovascular,Dyspnea on exertion/Syncope,checkbox,
Medical History,,Review of Systems,Cardiovascular,Irregular/Rapid heart rate,checkbox,
Medical History,,Review of Systems,Cardiovascular,Leg Pain/Cramping in legs at night,checkbox,
"Medical History,Oncology",,Review of Systems,,Genitourinary,checkbox,
Medical History,,Review of Systems,,Impotence,checkbox,
Medical History,,Review of Systems,Impotence,Incontinence /Difficulty Voiding,checkbox,
"Medical History,Neurology",,Review of Systems,Impotence,Kidney stones,checkbox,
Medical History,,Review of Systems,Impotence,Suprapubic/Indwelling Catheter,checkbox,
"Medical History,Neurology,Urology",,Review of Systems,Impotence,Urgency/Blood in Urine,checkbox,
Medical History,,Review of Systems,,Integumentary (Skin),radio,"yes,no"
Medical History,,Review of Systems,,New skin lesions/Skin Cancer,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,,Rash/Persistent itching,checkbox,
Medical History,,Review of Systems,,Unhealed/Delayed healing of sores,checkbox,
Medical History,,Review of Systems,,Heme/Lymphatic/Immune,radio,"yes,no"
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Anemia/Low platelet count,checkbox,
"Medical History,Neurology",,Review of Systems,Heme/Lymphatic/Immune,Bleeding disorder/Easy bleeding,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Easy bruising,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Lymphoma/Leukemia,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Frequent illnesses,checkbox,
ALLERGY/ASTHMA ,COUGH OR WHEEZE SYMPTOMS,,,,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DAYTIME SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,less than twice weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,more than twice weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,daily,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,"DAYTIME SYMPTOMS,NIGHT SYMPTOMS",continuous,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,NIGHT SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,less than twice monthly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,more than twice monthly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,nightly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DURING OR AFTER EXERCISE,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,exercise symptoms may occur,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,less than once weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,frequent exercise symptoms,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,significant limitation activity,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,EXTRA ALBUTEROL USE,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,occasional use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,periods of daily use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,daily use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,frequent daily need,checkbox,
ALLERGY/ASTHMA ,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,,,radio,"yes,no"
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,TRIGGERS OF COUGH OR WHEEZE:,radio,"yes,no"
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,colds/infection,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,morning,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,night,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,exercise,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,cold air,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,outdoors,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,paint fumes,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,changes in humidity,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,school/work environment,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"allergies  	",checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,stress,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,second hand smoke,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,tobacco use,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,perfume/aerosol sprays,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"mile run time  	",checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,pneumonia/bronchitis,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,MONTHS OF SYMPTOMS:,radio,"yes,no"
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",January,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 11 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",February,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 12 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",March,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 13 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",April,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 14 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",May,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 15 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",June,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 16 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",July,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 17 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",August,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 18 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",September,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 19 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",October,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 20 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",November,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 21 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",December,checkbox,
ALLERGY/ASTHMA ,ALLERGY - LIKE SYMPTOMS,,,,radio,"yes,no"
ALLERGY/ASTHMA ,,,,UPPER RESPIRATORY SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sneezing,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sniffing/drippy nose,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,itchy eyes/nose,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,dark circles under eyes,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sinus infection,checkbox,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,mouth breathing/snoring,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,congestion,checkbox,
"ALLERGY/ASTHMA, Oncology, Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,headaches,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,OTHER,text,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,eczema,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,hives,checkbox,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,dry skin,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,itchy skin,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,ear infection,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,nausea,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,dry cough,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,throat clearing,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,EXPOSURES,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,Smoke,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,fireplace/woodstove,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,animals,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,"feather (pillows, stuffed animals)",checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,carpeting,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom carpeting,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,forced air heat,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,mold in lower level,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,humidifier/vaporizer,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom in lower level,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,rural,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,city,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,suburbs,checkbox,
"ALLERGY/ASTHMA , Urology",,ALLERGY - LIKE SYMPTOMS,,ENVIRONMENTAL CONTROLS,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,air conditioning,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,HEPA filter,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,dehumidifier,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,wood floors,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,mattress & pillow covers,checkbox,
ALLERGY/ASTHMA ,TESTING/EVALUATION/EDUCATION:,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had a breathing/lung function test?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,Has the patient ever had a breathing/lung function test?,"If yes, when?",text,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at school/daycare?,radio,"yes,no"
ALLERGY/ASTHMA ,Please check those items which trigger your child’s allergy or asthma symptoms,,,,checkbox,"Dust,Cold Air,Exercise,Viral Infection,Ear or Sinus Infections,Weather Changes,Pollens,Cigarette Smoke,Strong odors,Cats,Dogs"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,, Has the patient ever had allergy testing?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient had their flu vaccine this year?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had flu vaccine?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at home? ,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have any questions about your action plan?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Have you received asthma information?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Would you like more information? ,radio,"classes,reading material,websites"
Cardiology,Personal History,,,,radio,"yes,no"
"Cardiology,Oncology,Neurology",,Personal History,,Dizziness or fainting,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Falls that caused an injury,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Stroke,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when walking 1 to 2 blocks,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when climbing 1 flight of stairs,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when lying down,radio,"Within last 30 days,In the past"
"Cardiology,Neurology,Urology",,Personal History,,Lower leg cramps while walking,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Bleeding problems or low iron (also called anemia),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Blood clot in leg (also called phlebitis),radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,High cholesterol,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Diabetes,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,High blood pressure,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Heart murmur or abnormal heart valve,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Uncomfortable feeling in the chest,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Chest pain with activity (also called angina),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Heart attack (also called myocardial infarction),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Swollen legs,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,ankles or feet,radio,"Within last 30 days,In the past"
"Cardiology,Oncology",,Personal History,,Irregular heartbeat,radio,"Within last 30 days,In the past"
Cardiology,Have you had any of the following tests or procedures,,,,radio,"yes,no"
Cardiology,,Have you had any of the following tests or procedures,,Stress test or treadmill test:,radio,
Cardiology,,Have you had any of the following tests or procedures,,Cardiac catheterization or angiogram:,radio,
Cardiology,,Have you had any of the following tests or procedures,,Angioplasty or stent,radio,
"Cardiology,Neurology",,Have you had any of the following tests or procedures,,"Heart surgery If so, what kind?",radio,"yes,no"
Cardiology,,Have you had any of the following tests or procedures,"Heart surgery If so, what kind?",please explain,text,
Cardiology,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,,,radio,"yes,no"
Cardiology,,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,"If YES, which meal plan or diet do you follow?",text,
Cardiology,Do you exercise regularly?,,,,radio,"yes,no"
Cardiology,,Do you exercise regularly?,,"If YES, how many days a week?",text,
"Oncology,Neruology",Fever over 100 degrees F,,,,checkbox,
"Oncology,Neurology",Bone pain,,,,checkbox,
"Oncology,Neruology",Joint pain or stiffness,,,,checkbox,
Oncology,Lumps under the skin,,,,checkbox,
Oncology,New spots,,,,checkbox,
Oncology,Sores that won’t heal,,,,checkbox,
Oncology,Yellowing of eyes or skin (jaundice),,,,checkbox,
Oncology,Serious cough that brings up a lot of mucus or phlegm,,,,checkbox,
"Oncology,Neruology","Weakness in hand, arm, or leg",,,,checkbox,
Oncology,Problems with balance,,,,checkbox,
Oncology,Dry mouth,,,,checkbox,
Oncology,Problems chewing,,,,checkbox,
Oncology,Problems swallowing,,,,checkbox,
Oncology,Problems remembering things,,,,checkbox,
Oncology,Hard time finding the right word,,,,checkbox,
Oncology,Hard time concentrating,,,,checkbox,
"Oncology,Neruology",Double vision,,,,checkbox,
Oncology,Sudden need to urinate,,,,checkbox,
"Oncology,urology",Leaking urine,,,,checkbox,
Oncology,Are you having pain now?,,,,radio,"yes,no"
Oncology,,Are you having pain now?,,"If YES, where is your pain?",text,
Oncology,,,,How often are you in pain?,text,
Oncology,,,,When did your pain start?,text,
Oncology,"How would you describe your pain on a scale from 0 to 10, with 0 being no pain and 10 being worst pain ever?",,,,radio,"0	,1,	2,	3,	4,	5,	6,	7,	8,	9,10"
Oncology,Are you controlling your pain with medicine?,,,,radio,"yes,no"
Oncology,,Are you controlling your pain with medicine?,,"If YES, what pain medicine do you take?",text,
Oncology,,,,How often do you take this pain medicine?,text,
Oncology,"Do you live in an Assisted Living Facility, Adult Family Home, Nursing Home?",,,,radio,"yes,no"
Oncology,May we give information about your health to another person?,,,,radio,"yes,no"
Oncology,,May we give information about your health to another person?,,Name of person,text,
Oncology,,May we give information about your health to another person?,,Relationship to you,text,
Oncology,Does anyone from Home Health or Hospice visit you at home?,,,,radio,"yes,no"
Oncology,Have you been able to continue most of your normal activities?,,,,radio,"yes,no"
Neurology, Atrial fibrillation,,,,checkbox,
Neurology,Bowel Problems,,,,checkbox,
Neurology,Crohn’s Disease,,,,checkbox,
Neurology,Loss of consciousness,,,,text,
Neurology,Parkinson’s Disease,,,,checkbox,
Neurology,Fibromyalgia,,,,checkbox,
Neurology,Stomach Ulcers,,,,text,
Neurology,Neck Surgery,,,,checkbox,
Neurology,Back Surgery,,,,checkbox,
Neurology,Aneurysm Surgery,,,,checkbox,
Neurology,Abdominal Surgery,,,,checkbox,
Neurology,Bowel Surgery,,,,checkbox,
Neurology,Bypass in the legs,,,,checkbox,
Neurology,Gallbladder Surgery,,,,checkbox,
Neurology,Gastric bypass surgery,,,,checkbox,
Neurology,Gynecologic surgery,,,,checkbox,
Neurology,Implants Type,,,,text,
Neurology,Intrathecal Pump,,,,checkbox,
Neurology,Pacemaker Surgery,,,,checkbox,
Neurology,Stimulator,,,,checkbox,
Neurology,Use caffeine,,,,checkbox,
Neurology,Street Drug,,,,text,
Neurology,Dementia,,,,radio,"yes,no"
Neurology,Epilepsy,,,,radio,"yes,no"
Neurology,Migraine Headaches,,,,radio,"yes,no"
Neurology,Polyneuropathy,,,,radio,"yes,no"
Neurology,Tremor,,,,radio,"yes,no"
Neurology,Poor memory,,,,checkbox,
Neurology,Difficulty finding words,,,,checkbox,
Neurology,Frequent sore throat,,,,checkbox,
Neurology,Hoarseness,,,,checkbox,
Neurology,Discharge from nose,,,,checkbox,
Neurology,Repeated sinus infections,,,,checkbox,
Neurology,Palpitations,,,,checkbox,
Neurology,Irregular heart beat,,,,checkbox,
Neurology,Cold hands,,,,checkbox,
Neurology,Cold feet,,,,checkbox,
Neurology,Chronic cough,,,,checkbox,
Neurology,Muscle loss,,,,checkbox,
"Neurology,urology",Excessive thirst,,,,checkbox,
Neurology,Farsighted,,,,checkbox,
Neurology,Nearsighted,,,,checkbox,
Neurology,Changes in hair,,,,checkbox,
Neurology,Changes in nails,,,,checkbox,
Neurology,Changes in skin color,,,,checkbox,
Neurology,Dry skin,,,,checkbox,
Dermatology,"Over the last week, how itchy, sore,painful or stinging has your skin been?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how embarrassed or self conscious have you been because of your skin?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin influenced the clothes you wear?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin affected any social or leisure activities?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin made it difficult for you to do any sport?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, has your skin prevented you from working or studying?",,,,radio,"yes,no"
Dermatology,"If ""No"", over the last week how much has your skin been a problem at work or studying?",,,,radio,"A lot,A little,Not at all"
Dermatology,"Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin caused any sexual difficulties?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?",,,,radio,"Very much,A lot,A little, Not at all"
Urology,Are you interested in smoking cessation counseling?,,,,radio,"yes,no"
Urology,Living Will or Power of Attorney,,,,checkbox,
Urology,Living Will or Power of Attorney,,,,checkbox,
Urology,Surrogate Designation (name/relation),,,,text,
"Medical History, Family history,Urology",Anesthesia Problems,,,,checkbox,
"Medical History, Family history,Urology",Urolithiasis (Urinary Stones),,,,checkbox,
Urology,extreme and insatiable hunger,,,,checkbox,
Urology,genital pain,,,,checkbox,
Urology,the sensation of pain and/or burning,,,,checkbox,
Urology,Urinary incontinence problem,,,,checkbox,
Urology,Genital Sore,,,,checkbox,