{
    "section": "subjective",
    "templateSet": "Back Pain",
    "templates": [
        {
            "text": "Reason for visit",
            "template": "Patient presents for {children}.",
            "children": [
                {
                    "text": "new onset symptom evaluation",
                    "template": "evaluation of new onset symptoms"
                },
                {
                    "text": "initial evaluation of back pain symptoms",
                    "template": "initial evaluation of back pain symptoms"
                },
                {
                    "text": "follow-up back pain evaluation",
                    "template": "follow-up evaluation of back pain"
                },
                {
                    "text": "ongoing back pain management",
                    "template": "ongoing management of back pain"
                },
                {
                    "text": "Visit reason (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Onset\/Time course",
            "template": "Condition {children}.",
            "children": [
                {
                    "text": "acute onset (new condition)",
                    "template": "is reported to have developed acutely"
                },
                {
                    "text": "chronic and ongoing condition",
                    "template": "is chronic and ongoing"
                },
                {
                    "text": "acutely worse (chronic condition)",
                    "template": "severity is reported to have acutely worsened"
                },
                {
                    "text": "progressively worsened",
                    "template": "is reported to have progressively worsened"
                },
                {
                    "text": "intermittent presence of symptoms",
                    "template": "symptoms are described as intermittently present"
                },
                {
                    "text": "Duration (hours)",
                    "template": "is reported as having been present for {text} hours",
                    "type": "number"
                },
                {
                    "text": "Duration (days)",
                    "template": "is reported as having been present for {text} days",
                    "type": "number"
                },
                {
                    "text": "Duration (weeks)",
                    "template": "is reported as having been present for {text} weeks",
                    "type": "number"
                },
                {
                    "text": "Duration (months)",
                    "template": "is reported as having been present for {text} months",
                    "type": "number"
                },
                {
                    "text": "Duration (years)",
                    "template": "is reported as having been present for {text} years",
                    "type": "number"
                },
                {
                    "text": "Duration (describe)",
                    "template": "is reported as having been present for {text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Symptoms\/Functional impact",
            "template": "Back pain is present and described as {children}.",
            "children": [
                {
                    "text": "Localization",
                    "template": "affecting the {children}",
                    "children": [
                        {
                            "text": "R upper back",
                            "template": "the R upper back"
                        },
                        {
                            "text": "L upper back",
                            "template": "the L upper back"
                        },
                        {
                            "text": "R scapula",
                            "template": "the R scapula"
                        },
                        {
                            "text": "L scapula",
                            "template": "the L scapula"
                        },
                        {
                            "text": "R midback",
                            "template": "the R midback"
                        },
                        {
                            "text": "L midback",
                            "template": "the L midback"
                        },
                        {
                            "text": "R flank",
                            "template": "the R flank"
                        },
                        {
                            "text": "L flank",
                            "template": "the L flank"
                        },
                        {
                            "text": "R lower back",
                            "template": "the R lower back"
                        },
                        {
                            "text": "L lower back",
                            "template": "the L lower back"
                        },
                        {
                            "text": "R buttocks",
                            "template": "the R buttocks"
                        },
                        {
                            "text": "L buttocks",
                            "template": "the L buttocks"
                        },
                        {
                            "text": "R hip",
                            "template": "the R hip"
                        },
                        {
                            "text": "L hip",
                            "template": "the L hip"
                        },
                        {
                            "text": "no specific area",
                            "template": "no specific area"
                        }
                    ]
                },
                {
                    "text": "Quality",
                    "template": "having {children} quality",
                    "children": [
                        {
                            "text": "pressure",
                            "template": "a pressure-like"
                        },
                        {
                            "text": "sharp",
                            "template": "a sharp"
                        },
                        {
                            "text": "dull",
                            "template": "a dull"
                        },
                        {
                            "text": "aching",
                            "template": "an aching"
                        },
                        {
                            "text": "cramping",
                            "template": "a cramping"
                        },
                        {
                            "text": "spasm",
                            "template": "a spasm-like"
                        },
                        {
                            "text": "electric",
                            "template": "an electric"
                        }
                    ]
                },
                {
                    "text": "Radiation",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "nonradiating",
                            "template": "nonradiating"
                        },
                        {
                            "text": "into R leg, above the knee",
                            "template": "radiating down into the R leg (above the knee)"
                        },
                        {
                            "text": "into L leg, above the knee",
                            "template": "radiating down into the L leg (above the knee)"
                        },
                        {
                            "text": "into both legs, above the knees",
                            "template": "radiating down into both legs (above the knees)"
                        },
                        {
                            "text": "into R leg, below the knee",
                            "template": "radiating down into the R leg (below the knee)"
                        },
                        {
                            "text": "into L leg, below the knee",
                            "template": "radiating down into the L leg (below the knee)"
                        },
                        {
                            "text": "into both legs, below the knees",
                            "template": "radiating down into the both legs (below the knees)"
                        },
                        {
                            "text": "R groin",
                            "template": "radiating into the R groin"
                        },
                        {
                            "text": "L groin",
                            "template": "radiating into the L groin"
                        }
                    ]
                },
                {
                    "text": "Severity (0-10, 10=worst)",
                    "template": "having a severity rated as {children}",
                    "children": [
                        {
                            "text": "mild",
                            "template": "mild"
                        },
                        {
                            "text": "moderate",
                            "template": "moderate"
                        },
                        {
                            "text": "severe",
                            "template": "severe"
                        },
                        {
                            "text": "0\/10 (no pain)",
                            "template": "0\/10 (no pain)"
                        },
                        {
                            "text": "+1\/10",
                            "template": "+1\/10 (10=worst)"
                        },
                        {
                            "text": "+2\/10",
                            "template": "+2\/10 (10=worst)"
                        },
                        {
                            "text": "+3\/10",
                            "template": "+3\/10 (10=worst)"
                        },
                        {
                            "text": "+4\/10",
                            "template": "+4\/10 (10=worst)"
                        },
                        {
                            "text": "+5\/10",
                            "template": "+5\/10 (10=worst)"
                        },
                        {
                            "text": "+6\/10",
                            "template": "+6\/10 (10=worst)"
                        },
                        {
                            "text": "+7\/10",
                            "template": "+7\/10 (10=worst)"
                        },
                        {
                            "text": "+8\/10",
                            "template": "+8\/10 (10=worst)"
                        },
                        {
                            "text": "+9\/10",
                            "template": "+9\/10 (10=worst)"
                        },
                        {
                            "text": "+10\/10",
                            "template": "+10\/10 (10=worst)"
                        }
                    ]
                },
                {
                    "text": "Timing: constant, intermittent",
                    "template": "being {children}",
                    "children": [
                        {
                            "text": "constantly present",
                            "template": "constantly present"
                        },
                        {
                            "text": "intermittently present",
                            "template": "intermittently present"
                        }
                    ]
                },
                {
                    "text": "Functional impact",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "no limitation of physical activity",
                            "template": "no limitation of physical activity"
                        },
                        {
                            "text": "slight limitation of physical activity",
                            "template": "slight limitation of physical activity"
                        },
                        {
                            "text": "marked limitation of physical activity",
                            "template": "marked limitation of physical activity"
                        },
                        {
                            "text": "unable to carry out any activity",
                            "template": "unable to carry out any activity without discomfort"
                        },
                        {
                            "text": "able to work",
                            "template": "able to work"
                        },
                        {
                            "text": "unable to work",
                            "template": "unable to work"
                        },
                        {
                            "text": "able to carry out usual activities",
                            "template": "able to carry out usual activities"
                        },
                        {
                            "text": "unable to carry out usual activities",
                            "template": "unable to carry out usual activities"
                        }
                    ]
                },
                {
                    "text": "Functional impact (describe)",
                    "template": "impaired functional status, described as {text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Pertinent positives\/negatives",
            "template": "Pertinent positive\/negative symptoms include: {children}.",
            "children": [
                {
                    "text": "fever",
                    "template": "fever",
                    "type": "plus-minus"
                },
                {
                    "text": "disturbed sleep",
                    "template": "disturbed sleep",
                    "type": "plus-minus"
                },
                {
                    "text": "dyspnea",
                    "template": "dyspnea",
                    "type": "plus-minus"
                },
                {
                    "text": "chest pain",
                    "template": "chest pain",
                    "type": "plus-minus"
                },
                {
                    "text": "abdominal pain",
                    "template": "abdominal pain",
                    "type": "plus-minus"
                },
                {
                    "text": "nausea",
                    "template": "nausea",
                    "type": "plus-minus"
                },
                {
                    "text": "vomiting",
                    "template": "vomiting",
                    "type": "plus-minus"
                },
                {
                    "text": "malar rash",
                    "template": "malar rash",
                    "type": "plus-minus"
                },
                {
                    "text": "psoriasis",
                    "template": "psoriasis",
                    "type": "plus-minus"
                },
                {
                    "text": "livedo reticularis",
                    "template": "livedo reticularis",
                    "type": "plus-minus"
                },
                {
                    "text": "giving out sensation in joint",
                    "template": "giving out sensation in joint",
                    "type": "plus-minus"
                },
                {
                    "text": "buckling sensation in joint",
                    "template": "buckling sensation in joint",
                    "type": "plus-minus"
                },
                {
                    "text": "locking sensation in joint",
                    "template": "locking sensation in joint",
                    "type": "plus-minus"
                },
                {
                    "text": "feeling of unstability",
                    "template": "feeling of unstability",
                    "type": "plus-minus"
                },
                {
                    "text": "multiple tender points",
                    "template": "multiple tender points",
                    "type": "plus-minus"
                },
                {
                    "text": "widespread pain",
                    "template": "widespread pain",
                    "type": "plus-minus"
                },
                {
                    "text": "unable to bear full weight",
                    "template": "unable to bear full weight",
                    "type": "plus-minus"
                },
                {
                    "text": "myalgias",
                    "template": "myalgias",
                    "type": "plus-minus"
                },
                {
                    "text": "paresthesias",
                    "template": "paresthesias",
                    "type": "plus-minus"
                },
                {
                    "text": "lower extremity numbness",
                    "template": "lower extremity numbness",
                    "type": "plus-minus"
                },
                {
                    "text": "lower extremity weakness",
                    "template": "lower extremity weakness",
                    "type": "plus-minus"
                },
                {
                    "text": "lower extremity edema",
                    "template": "lower extremity edema",
                    "type": "plus-minus"
                },
                {
                    "text": "other pertinent sx (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Exacerbating\/Alleviating factors",
            "template": "Patient reports that {children}.",
            "children": [
                {
                    "text": "Associated injury\/activity (specify)",
                    "template": "the condition was caused by {text}",
                    "type": "alpha"
                },
                {
                    "text": "Stress",
                    "template": "stress {children}",
                    "children": [
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Prolonged work at desk",
                    "template": "prolonged work at desk {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Lying down",
                    "template": "lying down {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Activity",
                    "template": "activity {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Rising in morning",
                    "template": "rising in the morning {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Walking",
                    "template": "walking {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Walking up stairs",
                    "template": "walking up stairs {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Rest",
                    "template": "rest {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been observed",
                            "template": "has not been observed"
                        }
                    ]
                },
                {
                    "text": "Exercise",
                    "template": "exercise {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been tried",
                            "template": "has not been tried"
                        }
                    ]
                },
                {
                    "text": "Massage",
                    "template": "massage {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been tried",
                            "template": "has not been tried"
                        }
                    ]
                },
                {
                    "text": "Yoga",
                    "template": "yoga {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been tried",
                            "template": "has not been tried"
                        }
                    ]
                },
                {
                    "text": "NSAIDs",
                    "template": "NSAIDs {children}",
                    "children": [
                        {
                            "text": "improve sx",
                            "template": "improve sx"
                        },
                        {
                            "text": "worsen sx",
                            "template": "worsen sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "have no effect on sx"
                        },
                        {
                            "text": "have not been tried",
                            "template": "have not been tried"
                        }
                    ]
                },
                {
                    "text": "Acetaminophen",
                    "template": "acetaminophen {children}",
                    "children": [
                        {
                            "text": "improves sx",
                            "template": "improves sx"
                        },
                        {
                            "text": "worsens sx",
                            "template": "worsens sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "has no effect on sx"
                        },
                        {
                            "text": "has not been tried",
                            "template": "has not been tried"
                        }
                    ]
                },
                {
                    "text": "Opioids",
                    "template": "opioids {children}",
                    "children": [
                        {
                            "text": "improve sx",
                            "template": "improve sx"
                        },
                        {
                            "text": "worsen sx",
                            "template": "worsen sx"
                        },
                        {
                            "text": "no effect on sx",
                            "template": "have no effect on sx"
                        },
                        {
                            "text": "have not been tried",
                            "template": "have not been tried"
                        }
                    ]
                },
                {
                    "text": "Other contributing factors (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Tx response\/Side effects",
            "template": "Treatment effects: {children}.",
            "children": [
                {
                    "text": "adherent to current tx",
                    "template": "adherent to current tx"
                },
                {
                    "text": "nonadherent to current tx",
                    "template": "nonadherent to current tx"
                },
                {
                    "text": "Reasons for nonadherence",
                    "template": "reasons for nonadherence include {children}",
                    "children": [
                        {
                            "text": "side effects",
                            "template": "side effects"
                        },
                        {
                            "text": "nausea",
                            "template": "nausea"
                        },
                        {
                            "text": "stomach upset",
                            "template": "stomach upset"
                        },
                        {
                            "text": "diarrhea",
                            "template": "diarrhea"
                        },
                        {
                            "text": "swallowing difficulty",
                            "template": "difficulty swallowing"
                        },
                        {
                            "text": "cost",
                            "template": "cost"
                        },
                        {
                            "text": "difficulty scheduling",
                            "template": "difficulty scheduling"
                        },
                        {
                            "text": "forgetfulness",
                            "template": "forgetfulness"
                        },
                        {
                            "text": "no perceived need for tx",
                            "template": "no perceived need for treatment"
                        }
                    ]
                },
                {
                    "text": "Nonadherence (describe)",
                    "template": "nonadherent to tx ({text})",
                    "type": "alpha"
                },
                {
                    "text": "Treatment response",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "resolved with treatment",
                            "template": "resolved with treatment"
                        },
                        {
                            "text": "well-controlled on treatment",
                            "template": "well-controlled on treatment"
                        },
                        {
                            "text": "improving on treatment",
                            "template": "improving on treatment"
                        },
                        {
                            "text": "stable on treatment",
                            "template": "stable on treatment"
                        },
                        {
                            "text": "unchanged on treatment",
                            "template": "unchanged on treatment"
                        },
                        {
                            "text": "variable response to treatment",
                            "template": "variable response to treatment"
                        },
                        {
                            "text": "suboptimally-controlled on treatment",
                            "template": "suboptimally-controlled on treatment"
                        },
                        {
                            "text": "poorly-controlled on treatment",
                            "template": "poorly-controlled on treatment"
                        },
                        {
                            "text": "worsening on treatment",
                            "template": "worsening on treatment"
                        },
                        {
                            "text": "exacerbated despite treatment",
                            "template": "exacerbated despite treatment"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Medical Hx specific to visit",
            "template": "Medical history includes {children}",
            "children": [
                {
                    "text": "overweight\/obesity",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "overweight",
                            "template": "overweight",
                            "type": "plus-minus"
                        },
                        {
                            "text": "obese",
                            "template": "obese",
                            "type": "plus-minus"
                        },
                        {
                            "text": "morbid obesity",
                            "template": "morbid obesity",
                            "type": "plus-minus"
                        }
                    ]
                },
                {
                    "text": "obesity contributing factors (describe)",
                    "template": "obesity contributing factors {text}",
                    "type": "alpha"
                },
                {
                    "text": "rheumatoid arthritis",
                    "template": "rheumatoid arthritis",
                    "type": "plus-minus"
                },
                {
                    "text": "osteoarthritis",
                    "template": "osteoarthritis",
                    "type": "plus-minus"
                },
                {
                    "text": "osteoporosis",
                    "template": "osteoporosis",
                    "type": "plus-minus"
                },
                {
                    "text": "scoliosis",
                    "template": "scoliosis",
                    "type": "plus-minus"
                },
                {
                    "text": "osteomyelitis",
                    "template": "osteomyelitis",
                    "type": "plus-minus"
                },
                {
                    "text": "tuberculosis",
                    "template": "tuberculosis",
                    "type": "plus-minus"
                },
                {
                    "text": "glucocorticoid use",
                    "template": "glucocorticoid use",
                    "type": "plus-minus"
                },
                {
                    "text": "immunosuppression",
                    "template": "immunosuppression",
                    "type": "plus-minus"
                },
                {
                    "text": "diabetes type 1",
                    "template": "diabetes type 1",
                    "type": "plus-minus"
                },
                {
                    "text": "diabetes type 2",
                    "template": "diabetes type 2",
                    "type": "plus-minus"
                },
                {
                    "text": "depression",
                    "template": "depression",
                    "type": "plus-minus"
                },
                {
                    "text": "Collagen vascular disease",
                    "template": "specified collagen vascular disease: {text}",
                    "type": "alpha"
                },
                {
                    "text": "Trauma history (describe)",
                    "template": "history of trauma: {text}",
                    "type": "alpha"
                },
                {
                    "text": "Back injury history (describe)",
                    "template": "history of back injury: {text}",
                    "type": "alpha"
                },
                {
                    "text": "Back surgery history (describe)",
                    "template": "history of back surgery: {text}",
                    "type": "alpha"
                },
                {
                    "text": "Cancer history (describe)",
                    "template": "history of cancer: {text}",
                    "type": "alpha"
                },
                {
                    "text": "other medical Hx (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Lifestyle\/Environment factors",
            "template": "Lifestyle\/Environment factors include {children}.",
            "children": [
                {
                    "text": "occupation",
                    "template": "occupation: {text}",
                    "type": "alpha"
                },
                {
                    "text": "alcohol use",
                    "template": "alcohol use",
                    "type": "plus-minus"
                },
                {
                    "text": "IVDU",
                    "template": "IVDU",
                    "type": "plus-minus"
                },
                {
                    "text": "other lifestyle\/exposure (specify)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Smoking status",
            "template": "Smoking status: {children}.",
            "children": [
                {
                    "text": "nonsmoker",
                    "template": "nonsmoker"
                },
                {
                    "text": "tobacco abuse",
                    "template": "tobacco abuse",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco dependence",
                    "template": "tobacco dependence",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco products used",
                    "template": "tobacco products used include {children}",
                    "children": [
                        {
                            "text": "cigarettes",
                            "template": "cigarettes"
                        },
                        {
                            "text": "cigars",
                            "template": "cigars"
                        },
                        {
                            "text": "pipes",
                            "template": "pipes"
                        },
                        {
                            "text": "water pipes",
                            "template": "water pipes"
                        },
                        {
                            "text": "chew",
                            "template": "chew"
                        },
                        {
                            "text": "snuff",
                            "template": "snuff"
                        }
                    ]
                },
                {
                    "text": "packs per day (specify)",
                    "template": "{text} packs per day",
                    "type": "number"
                },
                {
                    "text": "age at smoking onset (specify)",
                    "template": "started smoking at age {text}",
                    "type": "number"
                },
                {
                    "text": "smoking duration (months)",
                    "template": "smoking duration is {text} months",
                    "type": "number"
                },
                {
                    "text": "smoking duration (years)",
                    "template": "smoking duration is {text} years",
                    "type": "number"
                },
                {
                    "text": "tobacco withdrawal",
                    "template": "tobacco withdrawal",
                    "type": "plus-minus"
                },
                {
                    "text": "tobacco remission",
                    "template": "tobacco remission",
                    "type": "plus-minus"
                },
                {
                    "text": "hx of nicotine dependence (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "second hand smoke type\/exposure (describe)",
                    "template": "{text}",
                    "type": "alpha"
                },
                {
                    "text": "other (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        }
    ]
}