<htmlform>
<div id="divCheckbox"  style="display: none;" >
	<section headerLabel="1. Encounter Details">
		<table class="baseline-aligned">
			<tr>
				<td>Date:</td>
				<td><encounterDate default="today"/></td>
			</tr>
			<tr>
				<td>Location:</td>
				<td><encounterLocation default="1"/></td>
			</tr>
			<tr>
				<td>Provider:</td>
                                <td><encounterProviderAndRole encounterRole="1" default="1"/></td>
			</tr>
			<tr>
				<td>Status:</td>
                                <td><obs conceptId="15" default="Under-Review" /></td>
			</tr>
		</table>
	</section>
</div>

<br/><br/>

	<section headerLabel="-- Demographics">
		<table class="baseline-aligned">
			<tr>
				<td>Name:</td>
				<td><obs conceptId="12" /></td>
			</tr>
			<tr>
				<td>Gender:</td>
				<td><obs conceptId="13" /></td>
			</tr>
			<tr>
				<td>Age:</td>
				<td><obs conceptId="8" /></td>
			</tr>
			<tr>
				<td>Hometown:</td>
				<td><obs conceptId="7" /></td>
			</tr>
		</table>
	</section>

<br/><br/>

	<section headerLabel="-- Patient Narrative">
		<table class="baseline-aligned">
	                 <tr>
				<td>Subject:</td>
				<td><obs conceptId="16" /></td>
			</tr>
			<tr>
				<td>Narrative:</td>
				<td><obs conceptId="9" /></td>
			</tr>
		</table>
	</section>

<br/><br/>

	<section headerLabel="-- Patient Contact details">
		<table class="baseline-aligned">
			<tr>
				<td>Email:</td>
				<td><obs conceptId="10" /></td>
			</tr>
			<tr>
				<td>Telephone:</td>
				<td><obs conceptId="11" /></td>
			</tr>
		</table>
	</section>

<br/>

</htmlform>