<label> First Name *
        [text* your-first-name autocomplete:first-name] </label>
    
    
    <label> Last Name *
        [text* your-last-name autocomplete:last-name] </label>
    


<label> Patient Age *
    [number* patient-age] </label>

<label> Prefered Name / Nickname *
    [text* patient-name] </label>

<label> Patient Gender *
    [select* patient-gender first_as_label "-select-" "Male" "Female" "Shemale"] </label>

<label> Phone Number *
    [phone* phone validation:1] </label>

<label> Spouce Name
    [text spouce-name] </label>

<label> With whome do you live?
    [text live] </label>

<label> Marital Status *
    [select* marital-status first_as_label "-select-" "Married" "Unmarried" "other"]</label>

<label> Marital status(other)
    [text marital-status-other]</label>

<label> Occupation
    [text occupation]</label>

<label> Retired? *
    [select* retired first_as_label "-select-" "Yes" "No"]</label>


<label> Date of retirement
    [date_time date_time-743 "m/d/Y"]</label>


<label> Disability ? *
    [select* disability first_as_label "-select-" "Yes" "No"]</label>

<label> Who is your primary care doctor: 
    [text primary-care-doctor]</label>

<label> Where is your primary care doctor located ?
    [text primary-care-doctor-located]</label>

<label> Phone Number of primary care doctor:
    [phone* care-doctor-phone validation:1]</label>

<label> Allergic to any medications
    [select allergic first_as_label "-select-" "Yes" "No"]</label>

<label> Allergic to any medications
    [text allergic-medications]</label>

<label> Do you smoke? 
    [select smoke first_as_label "-select-" "Yes" "No"]</label>


    <label> How many years did you smoke?
        [number smoke-year]</label>


<label> If you quit, when did you stop?
    [text smoke-stop]</label>

<label> Do you drink alcohol? 
    [text drink-alcohol]</label>

<label> Personal opinion
    [textarea personal-opinion x3]</label>

[submit "Submit"]