gistfile1.php

<?php

$survey = array(
  'Q0' => array(
		'number' => false,
		'prompt' => 'Email Address:',
		'type' => 'email',
		'input_attribs' => 'type="email" placeholder="e.g. [email protected]" required autofocus'
	),
	'Q1' => array(
		'type' => 'radios',
		'options' => array(
			'A' => 'I am interested in receiving email alerts from n=2 as a journalist or blogger.',
			'B' => 'I am a patient diagnosed with ALS (Amyotrophic Lateral Sclerosis, also Lou Gehrig\'s Disease and Motor Neurone Disease)',
			'C' => 'I am a caregiver (spouse, other relative, friend or health care professional) for a single patient diagnosed with ALS.',
			'D' => 'I am a health care professional working with more than one patient diagnosed with ALS.'
		)
	),
	'Q2' => array(
		'prompt' => 'I live in',
		'type' => 'select',
		'options' => array_merge(array(''=>'(choose one)'), $countries),
		'input_attribs' => 'required'
	),
	'Q3' => array(
		'prompt' => 'My primary language is',
		'type' => 'select',
		'options' => array_merge(array(''=>'(choose one)'), $languages),
		'input_attribs' => 'required'
	),
	'Q4' => array(
		'prompt' => 'I also can read and understand the following languages',
		'type' => 'checkboxes',
		'columns' => 2,
		'options' => $languages
	),
	'Q5' => array(
		'prompt' => 'The ALS patient has... (check all that apply)',
		'type' => 'checkboxes',
		'columns' => 1,
		'options' => array(
			'A' => 'has received a diagnosis of POSSIBLE ALS from a health care professional.',
			'B' => 'has received a diagnosis of PROBABLE ALS from a health care professional.',
			'C' => 'has received a diagnosis of DEFINITIVE ALS from a health care professional.',
			'D' => 'has NOT YET received a diagnosis of possible, probable, or definitive ALS from a health care professional.',
		)
	),
	'Q6' => array(
		'prompt' => 'How long ago did the patient first receive a diagnosis of POSSIBLE, PROBABLE or DEFINITIVE ALS (use whichever diagnosis came FIRST, regardless of whether it was a diagnosis of possible, probable, or definitive ALS)?',
		'type' => 'radios',
		'options' => array(
			'A' => '0 - 3 months ago',
			'B' => '4 - 6 months ago',
			'C' => '7 - 11 months ago',
			'D' => '1 - 2 years ago',
			'E' => '3 -4 years ago',
			'F' => '5 - 7 years ago',
			'G' => '8 - 10 years ago',
			'H' => 'More than 10 years ago',
			'I' => 'The patient has not yet received a diagnosis of POSSIBLE, PROBABLE, or DEFINITIVE ALS.'
		)
	),
	'Q5A' => array(
		'prompt' => 'I am a',
		'type' => 'radios',
		'options' => array(
			'A' =>  'Doctor',
			'B' =>  'Nurse, Nurse Practitioner, or Physician\'s Assistant',
			'C' =>  'Health Care Professional, but not a doctor, nurse, or physician\'s assistant'
		)
	),
	'Q6A' => array(
		'prompt' => 'I help care for',
		'type' => 'radios',
		'options' => array(
			'A' =>  '1 ALS patient',
			'B' =>  '2 - 5 ALS patients',
			'C' =>  '6 - 10 ALS patients',
			'D' =>  '11 - 20 ALS patients',
			'E' =>  'More than 20 ALS patients'
		)
	)
);