Support for "SRV" and "Text with Memo"

app/Console/Commands/Gem.php

@@ -94,11 +94,49 @@ class Gem extends Command
                     $output .= $this->ln('</label>', $_level + 2);
 
                     // MEMO
-                    $output .= $this->ln('<input name="' . $key . '_memo" type="text" class="form-control form-control-sm">', $_level + 2);
+                    $output .= $this->ln('<input name="' . $key . '_memo" type="text" class="form-control form-control-sm" placeholder="Memo">', $_level + 2);
 
                     // end
                     $output .= $this->ln('</div>', $_level + 1);
                     break;
+
+                case 'SRV':
+                    // start
+                    $output .= $this->ln('<div class="d-flex align-items-center">', $_level + 1);
+
+                    // VALUE
+                    $output .= $this->ln('<input name="' . $key . '" type="text" class="form-control form-control-sm" placeholder="Answer">', $_level + 2);
+
+                    // UNKNOWN
+                    $output .= $this->ln('<label class="d-inline-flex align-items-center my-0 ml-3 mr-2">', $_level + 2);
+                    $output .= $this->ln('<input name="' . $key . '" type="checkbox" class="mr-1">', $_level + 3);
+                    $output .= $this->ln('<span>Unknown</span>', $_level + 3);
+                    $output .= $this->ln('</label>', $_level + 2);
+
+                    // MEMO
+                    $output .= $this->ln('<input name="' . $key . '_memo" type="text" class="form-control form-control-sm" placeholder="Memo">', $_level + 2);
+
+                    // end
+                    $output .= $this->ln('</div>', $_level + 1);
+                    break;
+
+                case 'Text with Memo':
+                    // start
+                    $output .= $this->ln('<div class="d-flex align-items-center">', $_level + 1);
+
+                    // VALUE
+                    $output .= $this->ln('<input name="' . $key . '" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">', $_level + 2);
+
+                    // MEMO
+                    $output .= $this->ln('<input name="' . $key . '_memo" type="text" class="form-control form-control-sm" placeholder="Memo">', $_level + 2);
+
+                    // end
+                    $output .= $this->ln('</div>', $_level + 1);
+                    break;
+
+                default:
+                    dump("Unknown type: {$_node->T}");
+                    break;
             }
         }
 

gem/forms/new-patient-intake/build/form.blade.php

@@ -15,7 +15,7 @@
                 <input name="blood_ox__ever_used_fingertip_meter" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="blood_ox__ever_used_fingertip_meter_memo" type="text" class="form-control form-control-sm">
+            <input name="blood_ox__ever_used_fingertip_meter_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="blood_ox__ever_used_fingertip_meter__has_one">
                 <label>Do you currently have one at home?</label>
@@ -32,7 +32,7 @@
                     <input name="blood_ox__ever_used_fingertip_meter__has_one" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="blood_ox__ever_used_fingertip_meter__has_one_memo" type="text" class="form-control form-control-sm">
+                <input name="blood_ox__ever_used_fingertip_meter__has_one_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -51,7 +51,7 @@
                     <input name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm">
+                <input name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -72,12 +72,20 @@
                 <input name="blood_ox__does_pcp_regularly_check" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="blood_ox__does_pcp_regularly_check_memo" type="text" class="form-control form-control-sm">
+            <input name="blood_ox__does_pcp_regularly_check_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
         <div class="my-3 node node-level-1" data-key="blood_ox__baseline_resting_spo2_level">
             <label>Do you know what your baseline resting oxygen saturation usually measures at?</label>
+        <div class="d-flex align-items-center">
+            <input name="blood_ox__baseline_resting_spo2_level" type="text" class="form-control form-control-sm" placeholder="Answer">
+            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                <input name="blood_ox__baseline_resting_spo2_level" type="checkbox" class="mr-1">
+                <span>Unknown</span>
+            </label>
+            <input name="blood_ox__baseline_resting_spo2_level_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+        </div>
         </div>
 
         <div class="my-3 node node-level-1" data-key="blood_ox__lung_condition_that_may_affect">
@@ -95,7 +103,7 @@
                 <input name="blood_ox__lung_condition_that_may_affect" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="blood_ox__lung_condition_that_may_affect_memo" type="text" class="form-control form-control-sm">
+            <input name="blood_ox__lung_condition_that_may_affect_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
@@ -103,10 +111,18 @@
             <label>Blood oxygen values depend a lot on your level of physical activity.</label>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion">
                 <label>How many days per week do you currently perform aerobic exercise to the point that you can feel your lungs working harder and your heart beating faster?</label>
+            <div class="d-flex align-items-center">
+                <input name="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+                <input name="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion">
                 <label>How many total minutes per week on average would you say you are in a state of aerobic exercise, where you feel your lungs working harder and your heart beating faster?</label>
+            <div class="d-flex align-items-center">
+                <input name="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+                <input name="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise">
@@ -124,18 +140,30 @@
                     <input name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise_memo" type="text" class="form-control form-control-sm">
+                <input name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="blood_ox__o2_and_activity__baseline_o2_assessment">
                 <label>Once you receive the oxygen meter, we will need to call you to make sure you take a proper baseline resting measurement, and then another measurement after you have you walk for 1 minute. When is the best time and number to call usually?</label>
+            <div class="d-flex align-items-center">
+                <input name="blood_ox__o2_and_activity__baseline_o2_assessment" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+                <input name="blood_ox__o2_and_activity__baseline_o2_assessment_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
 <div class="subs pl-4">                <div class="my-3 node node-level-3" data-key="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call">
                     <label>Best time to call:</label>
+                <div class="d-flex align-items-center">
+                    <input name="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+                    <input name="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+                </div>
                 </div>
 
                 <div class="my-3 node node-level-3" data-key="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call">
                     <label>Best number to call:</label>
+                <div class="d-flex align-items-center">
+                    <input name="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+                    <input name="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+                </div>
                 </div>
 
 </div>            </div>
@@ -155,7 +183,7 @@
                     <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo" type="text" class="form-control form-control-sm">
+                <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -174,7 +202,7 @@
                     <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo" type="text" class="form-control form-control-sm">
+                <input name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -199,7 +227,7 @@
                 <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter_memo" type="text" class="form-control form-control-sm">
+            <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one">
                 <label>Do you currently have one at home?</label>
@@ -216,7 +244,7 @@
                     <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one_memo" type="text" class="form-control form-control-sm">
+                <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -235,7 +263,7 @@
                     <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm">
+                <input name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
@@ -243,16 +271,40 @@
 
         <div class="my-3 node node-level-1" data-key="pulse_and_bp__usual_resting_pulse">
             <label>What is your usual resting pulse?</label>
+        <div class="d-flex align-items-center">
+            <input name="pulse_and_bp__usual_resting_pulse" type="text" class="form-control form-control-sm" placeholder="Answer">
+            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                <input name="pulse_and_bp__usual_resting_pulse" type="checkbox" class="mr-1">
+                <span>Unknown</span>
+            </label>
+            <input name="pulse_and_bp__usual_resting_pulse_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+        </div>
         </div>
 
         <div class="my-3 node node-level-1" data-key="pulse_and_bp__usual_resting_bp">
             <label>What is your usual resting blood pressure?</label>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="pulse_and_bp__usual_resting_bp__systolic">
                 <label>Systolic</label>
+            <div class="d-flex align-items-center">
+                <input name="pulse_and_bp__usual_resting_bp__systolic" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="pulse_and_bp__usual_resting_bp__systolic" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="pulse_and_bp__usual_resting_bp__systolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="pulse_and_bp__usual_resting_bp__diastolic">
                 <label>Diastolic</label>
+            <div class="d-flex align-items-center">
+                <input name="pulse_and_bp__usual_resting_bp__diastolic" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="pulse_and_bp__usual_resting_bp__diastolic" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="pulse_and_bp__usual_resting_bp__diastolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
 </div>        </div>
@@ -272,7 +324,7 @@
                 <input name="pulse_and_bp__ever_dx_with_htn" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="pulse_and_bp__ever_dx_with_htn_memo" type="text" class="form-control form-control-sm">
+            <input name="pulse_and_bp__ever_dx_with_htn_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="pulse_and_bp__ever_dx_with_htn__on_bp_medications">
                 <label>Are you on any BP medication?</label>
@@ -289,12 +341,20 @@
                     <input name="pulse_and_bp__ever_dx_with_htn__on_bp_medications" type="radio" value="UNKNOWN" class="mr-1">
                     <span>Unknown</span>
                 </label>
-                <input name="pulse_and_bp__ever_dx_with_htn__on_bp_medications_memo" type="text" class="form-control form-control-sm">
+                <input name="pulse_and_bp__ever_dx_with_htn__on_bp_medications_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
             </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="pulse_and_bp__ever_dx_with_htn__who_treats">
                 <label>Who primarily treats your HTN?</label>
+            <div class="d-flex align-items-center">
+                <input name="pulse_and_bp__ever_dx_with_htn__who_treats" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="pulse_and_bp__ever_dx_with_htn__who_treats" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="pulse_and_bp__ever_dx_with_htn__who_treats_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
 </div>        </div>
@@ -303,16 +363,40 @@
             <label>Has your primary care physician, or another doctor, ever told you what your target BP should be?</label>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="pulse_and_bp__pcp_or_other_doc_bp_target__systolic">
                 <label>Systolic</label>
+            <div class="d-flex align-items-center">
+                <input name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic">
                 <label>Diastolic</label>
+            <div class="d-flex align-items-center">
+                <input name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
 </div>        </div>
 
         <div class="my-3 node node-level-1" data-key="pulse_and_bp__pulse_during_exercise">
             <label>When you exercise, what does your pulse reach?</label>
+        <div class="d-flex align-items-center">
+            <input name="pulse_and_bp__pulse_during_exercise" type="text" class="form-control form-control-sm" placeholder="Answer">
+            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                <input name="pulse_and_bp__pulse_during_exercise" type="checkbox" class="mr-1">
+                <span>Unknown</span>
+            </label>
+            <input name="pulse_and_bp__pulse_during_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+        </div>
         </div>
 
 </div>    </div>
@@ -334,7 +418,7 @@
                 <input name="temp_thermometer__ever_used_itg_before" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="temp_thermometer__ever_used_itg_before_memo" type="text" class="form-control form-control-sm">
+            <input name="temp_thermometer__ever_used_itg_before_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
@@ -353,7 +437,7 @@
                 <input name="temp_thermometer__usual_resting_temp" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="temp_thermometer__usual_resting_temp_memo" type="text" class="form-control form-control-sm">
+            <input name="temp_thermometer__usual_resting_temp_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
@@ -372,7 +456,7 @@
                 <input name="temp_thermometer__do_you_or_someone_at_home_go_outdoors" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="temp_thermometer__do_you_or_someone_at_home_go_outdoors_memo" type="text" class="form-control form-control-sm">
+            <input name="temp_thermometer__do_you_or_someone_at_home_go_outdoors_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
@@ -391,7 +475,7 @@
                 <input name="temp_thermometer__will_you_check_people_temp_before_they_come_near" type="radio" value="UNKNOWN" class="mr-1">
                 <span>Unknown</span>
             </label>
-            <input name="temp_thermometer__will_you_check_people_temp_before_they_come_near_memo" type="text" class="form-control form-control-sm">
+            <input name="temp_thermometer__will_you_check_people_temp_before_they_come_near_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
         </div>
         </div>
 
@@ -403,18 +487,50 @@
             <label>What is your current:</label>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="bmi__current__height_in_inches">
                 <label>Height in inches?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__current__height_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__current__height_in_inches" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__current__height_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="bmi__current__weight_in_pounds">
                 <label>Weight in pounds?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__current__weight_in_pounds" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__current__weight_in_pounds" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__current__weight_in_pounds_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="bmi__current__waistline_in_inches">
                 <label>Waistline in inches?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__current__waistline_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__current__waistline_in_inches" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__current__waistline_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="bmi__current__body_fat_percent">
                 <label>Body fat %?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__current__body_fat_percent" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__current__body_fat_percent" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__current__body_fat_percent_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
 </div>        </div>
@@ -423,24 +539,60 @@
             <label>When you were 20 years old, what was your:</label>
 <div class="subs pl-4">            <div class="my-3 node node-level-2" data-key="bmi__at_20_years_old__weight_in_pounds">
                 <label>Weight in pounds?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__at_20_years_old__weight_in_pounds" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__at_20_years_old__weight_in_pounds" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__at_20_years_old__weight_in_pounds_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="bmi__at_20_years_old__waistline_in_inches">
                 <label>Waistline in inches?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__at_20_years_old__waistline_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__at_20_years_old__waistline_in_inches" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__at_20_years_old__waistline_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
             <div class="my-3 node node-level-2" data-key="bmi__at_20_years_old__height_in_inches">
                 <label>Height in inches?</label>
+            <div class="d-flex align-items-center">
+                <input name="bmi__at_20_years_old__height_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
+                <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                    <input name="bmi__at_20_years_old__height_in_inches" type="checkbox" class="mr-1">
+                    <span>Unknown</span>
+                </label>
+                <input name="bmi__at_20_years_old__height_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+            </div>
             </div>
 
 </div>        </div>
 
         <div class="my-3 node node-level-1" data-key="bmi__weight_goal_today">
             <label>Personal weight goal today</label>
+        <div class="d-flex align-items-center">
+            <input name="bmi__weight_goal_today" type="text" class="form-control form-control-sm" placeholder="Answer">
+            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
+                <input name="bmi__weight_goal_today" type="checkbox" class="mr-1">
+                <span>Unknown</span>
+            </label>
+            <input name="bmi__weight_goal_today_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+        </div>
         </div>
 
         <div class="my-3 node node-level-1" data-key="bmi__barriers_to_exercise">
             <label>Do you currently have any conditions, such as arthritis or joint pain, that limit your ability to exercise?</label>
+        <div class="d-flex align-items-center">
+            <input name="bmi__barriers_to_exercise" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
+            <input name="bmi__barriers_to_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
+        </div>
         </div>
 
 </div>    </div>