{
  "fields": {
    "complaint": {
      "label": "Chief Complaint:",
      "type": "checkbox"
    },
    "complaint_other": {
      "label": "Other Complaint:",
      "helper": "If Chief Complaint not listed above, please write in."
    },
    "symptom": {
      "label": "Symptoms:",
      "type": "checkbox"
    },
    "symptom_other": {
      "label": "Other Symptoms:",
      "type": "textarea"
    },
    "history": {
      "label": "History:",
      "type": "checkbox"
    },
    "history_other": {
      "label": "Other Past History:",
      "type": "textarea"
    },
    "note": {
      "label": "Examination Notes:",
      "type": "textarea"
    },
    "testing_method": {
      "label": "Tested By Following Method:",
      "type": "textarea"
    },
    "diagnosis": {
      "label": "Disease Diagnosis:",
      "type": "select"
    },
    "diagnosis_other": {
      "label": "Other Disease Diagnosis:"
    },
    "treatment": {
      "label": "Treatment:",
      "type": "textarea"
    },
    "admission": {
      "label": "Admission Required?",
      "type": "radio",
      "enum": [
        "Yes",
        "No"
      ],
      "removeDefaultNone": true
    },
    "disease_mortality": {
      "label": "Did Disease Lead To Death?",
      "type": "radio",
      "enum": [
        "Yes",
        "No"
      ],
      "removeDefaultNone": true
    },
    "referral": {
      "label": "Referral?",
      "type": "radio",
      "enum": [
        "Yes",
        "No"
      ],
      "removeDefaultNone": true
    },
    "referral_location": {
      "label": "If Yes, Referral Location:",
      "type": "select"
    }
  }
}