Make a Template

"Validate" would process the entry and either indicate syntax errors or display what the page will look like.

All of these would be populated by the system:

{title} - looks up this patient's stored title from a field of the same name
{lastname} - looks up this patient's stored last name
{!ageold} - the ! indicates that this is a function called "ageold" which calculates the patient's age by subtracting DOB from today() and providing the age in years, month or weeks depending on appropriate parameters.
{!descriptionarea} - would be an area for free text with security to eliminate hacking attempts - it could be blank.

All of the rest would be populated by the physician:

[0..30] - would create a number field or select list that was limited to the identified range
[hour|day|week|month|year] - would require a choice between them, probably best from select list
[|not] - would indicate a null choice is acceptable (or no choice) - probably best represented by a checkbox (chosen would include what follows)
[bloody|non-bloody] - would be a mandatory choice between the two, either radio style or select list