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    [select* Country "United States" "Canada" placeholder"Country"]
    [select US-States "Alabama" "Alaska" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "Florida" "Georgia" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming" placeholder"US State"]
    [select Canadian "Alberta" "British Columbia" "Manitoba" "New Brunswick" "Newfoundland" "Labrador" "Northwest Territories" "Nova Scotia" "Nunavut" "Ontario" "Prince Edward Island" "Quebec" "Saskatchewan" "Yukon" placeholder"Canadian Providence" placeholder"Canadian Providence"]



    Chronic PainAnxiety/StressFibromyalgiaDiabetes - Adult OnsetChronic Fatigue SyndromeHypertensionMigrainesNeck PainBack PainChronic IllnessPhantom PainPrescription Drug AddictionFailed SurgeryLupus
    [select Treatmentbefor "Yes " "No" placeholder"have you been treated before?"]