diff --git a/pwa/package-lock.json b/pwa/package-lock.json
index 2202d87..d085876 100644
--- a/pwa/package-lock.json
+++ b/pwa/package-lock.json
@@ -2198,9 +2198,9 @@
       },
       "dependencies": {
         "acorn": {
-          "version": "6.4.0",
-          "resolved": "https://registry.npmjs.org/acorn/-/acorn-6.4.0.tgz",
-          "integrity": "sha512-gac8OEcQ2Li1dxIEWGZzsp2BitJxwkwcOm0zHAJLcPJaVvm58FRnk6RkuLRpU1EujipU2ZFODv2P9DLMfnV8mw=="
+          "version": "6.4.1",
+          "resolved": "https://registry.npmjs.org/acorn/-/acorn-6.4.1.tgz",
+          "integrity": "sha512-ZVA9k326Nwrj3Cj9jlh3wGFutC2ZornPNARZwsNYqQYgN0EsV2d53w5RN/co65Ohn4sUAUtb1rSUAOD6XN9idA=="
         }
       }
     },
@@ -7866,9 +7866,9 @@
       },
       "dependencies": {
         "acorn": {
-          "version": "6.4.0",
-          "resolved": "https://registry.npmjs.org/acorn/-/acorn-6.4.0.tgz",
-          "integrity": "sha512-gac8OEcQ2Li1dxIEWGZzsp2BitJxwkwcOm0zHAJLcPJaVvm58FRnk6RkuLRpU1EujipU2ZFODv2P9DLMfnV8mw=="
+          "version": "6.4.1",
+          "resolved": "https://registry.npmjs.org/acorn/-/acorn-6.4.1.tgz",
+          "integrity": "sha512-ZVA9k326Nwrj3Cj9jlh3wGFutC2ZornPNARZwsNYqQYgN0EsV2d53w5RN/co65Ohn4sUAUtb1rSUAOD6XN9idA=="
         },
         "jsdom": {
           "version": "14.1.0",
@@ -8807,9 +8807,9 @@
       },
       "dependencies": {
         "acorn": {
-          "version": "5.7.3",
-          "resolved": "https://registry.npmjs.org/acorn/-/acorn-5.7.3.tgz",
-          "integrity": "sha512-T/zvzYRfbVojPWahDsE5evJdHb3oJoQfFbsrKM7w5Zcs++Tr257tia3BmMP8XYVjp1S9RZXQMh7gao96BlqZOw=="
+          "version": "5.7.4",
+          "resolved": "https://registry.npmjs.org/acorn/-/acorn-5.7.4.tgz",
+          "integrity": "sha512-1D++VG7BhrtvQpNbBzovKNc1FLGGEE/oGe7b9xJm/RFHMBeUaUGpluV9RLjZa47YFdPcDAenEYuq9pQPcMdLJg=="
         }
       }
     },
diff --git a/pwa/src/App.tsx b/pwa/src/App.tsx
index 8ac8774..db766c4 100644
--- a/pwa/src/App.tsx
+++ b/pwa/src/App.tsx
@@ -8,6 +8,7 @@ import Login from './components/Login'
 import LandingPage from './components/LandingPage'
 import Wrapper from './Wrapper'
 import PatientInfoForm from './components/PatientInfoForm'
+import DiagnosisForm from './components/DiagnosisForm'
 
 import './scss/App.scss'
 import './antd-mobile.css'
@@ -33,6 +34,15 @@ const App: React.FunctionComponent = () => {
                             <PatientInfoForm />
                         </Wrapper>
                     </Route>
+                    <Route path="/diagnosis">
+                    <Wrapper
+                        navTitle="Diagnosis"
+                        leftArrowText="Patient Info"
+                        leftArrowRoute="/patientinfo"
+                    >
+                        <DiagnosisForm />
+                    </Wrapper>
+                </Route>
                     <Route path="/easy-peasy">
                         <DebugShowEasyPeasy />
                     </Route>
diff --git a/pwa/src/components/DiagnosisFields.json b/pwa/src/components/DiagnosisFields.json
new file mode 100644
index 0000000..7c43993
--- /dev/null
+++ b/pwa/src/components/DiagnosisFields.json
@@ -0,0 +1,189 @@
+{
+    "diagnoses": [
+        {
+            "name": "Asthma",
+            "id": "asthma"
+        },
+        {
+            "name": "Allergies",
+            "id": "allergies"
+        },
+        {
+            "name": "Anemia",
+            "id": "anemia"
+        },
+        {
+            "name": "Malnutrition",
+            "id": "malnutrition"
+        },
+        {
+            "name": "Depression",
+            "id": "depression"
+        },
+        {
+            "name": "Diabetes",
+            "id": "diabetes"
+        },
+        {
+            "id": "eye",
+            "group-title": "Eye",
+            "group": [
+                {
+                    "name": "Ptergium",
+                    "id": "ptergium"
+                },
+                {
+                    "name": "Cataract",
+                    "id": "cataract"
+                },
+                {
+                    "name": "Dry Eye",
+                    "id": "dry-eye"
+                },
+                {
+                    "name": "Conjuntivitis",
+                    "id": "conjuntivitis"
+                }
+            ]
+        },
+        {
+            "name": "Fever",
+            "id": "fever"
+        },
+        {
+            "name": "Possible Malaria",
+            "id": "malaria"
+        },
+        {
+            "name": "Filariasis",
+            "id": "filariasis"
+        },
+        {
+            "id": "intestinal",
+            "group-title": "Intestinal",
+            "group": [
+                { "name": "Gastritis", "id": "gastritis" },
+                { "name": "GERD", "id": "gerd" },
+                { "name": "Gastroenteritis", "id": "gastroenteritis" },
+                { "name": "Dysentery", "id": "dysentery" },
+                { "name": "Possible Cholera", "id": "cholera" }
+            ]
+        },
+        {
+            "name": "Headache",
+            "id": "headache"
+        },
+        {
+            "group-title": "Hernia",
+            "id": "hernia",
+            "group": [
+                { "name": "Inguinal", "id": "inguinal" },
+                { "name": "Umbilical", "id": "umbilical" }
+            ]
+        },
+        {
+            "id": "cardiovascular",
+            "group-title": "Cardiovascular",
+            "group": [
+                { "name": "Hypertension", "id": "hypertension" },
+                { "name": "Stroke", "id": "stroke" },
+                { "name": "Angina", "id": "angina" },
+                { "name": "CHF", "id": "chf" }
+            ]
+        },
+        {
+            "name": "Healthy",
+            "id": "healthy"
+        },
+
+        {
+            "name": "Musculoskeletal Pain",
+            "id": "musculoskeletal"
+        },
+        {
+            "group-title": "Otitis",
+            "id": "otitis",
+            "group": [
+                { "name": "Right", "id": "otitis-right" },
+                { "name": "Left", "id": "otitis-left" }
+            ]
+        },
+        {
+            "name": "Pneumonia",
+            "id": "pneumonia"
+        },
+        {
+            "id": "sinusitis",
+            "name": "Sinusitis"
+        },
+        {
+            "name": "URI",
+            "id": "uri"
+        },
+        {
+            "name": "Pregnancy",
+            "id": "pregnancy",
+            "text-input-title": "Weeks",
+            "text-input-type": "number",
+            "max-length": 2,
+            "text-input-id": "pregnancy-weeks"
+        },
+        {
+            "group-title": "Dermatological",
+            "id": "dermatological",
+            "group": [
+                { "name": "Atopic Derm", "id": "atopic-derm" },
+                { "name": "Fungal", "id": "fungal" },
+                { "name": "Scabies", "id": "scabies" },
+                { "name": "Impetigo", "id": "Impetigo" },
+                { "name": "Tinea Capitus (kerion)", "id": "tinea-capitus" }
+            ]
+        },
+        {
+            "name": "Possible STD",
+            "id": "std"
+        },
+        {
+            "name": "Possible TB",
+            "id": "tb"
+        },
+        {
+            "name": "Possible Parasites",
+            "id": "parasites"
+        },
+        {
+            "name": "UTI",
+            "id": "uti"
+        },
+        {
+            "group-title": "Vaginal",
+            "id": "vaginal",
+            "group": [
+                { "name": "Vaginitis", "id": "vaginitis" },
+                { "name": "Candidal", "id": "candidal" },
+                { "name": "Trich", "id": "trich" },
+                { "name": "BV", "id": "bv" }
+            ]
+        },
+        {
+            "name": "Needs to see Dentist",
+            "id": "dentist"
+        },
+        {
+            "name": "Needs to see Eye Doctor",
+            "id": "eye-doctor"
+        },
+        {
+            "name": "Surgical candidate",
+            "id": "surgical-candidate"
+        },
+        {
+            "text-input-title": "Other Diagnosis",
+            "text-input-id": "other-diagnosis"
+        },
+        {
+            "text-input-title": "Diagnoses Comments",
+            "text-input-id": "comments"
+        }
+    ]
+}
diff --git a/pwa/src/components/DiagnosisForm.test.tsx b/pwa/src/components/DiagnosisForm.test.tsx
new file mode 100644
index 0000000..767f94a
--- /dev/null
+++ b/pwa/src/components/DiagnosisForm.test.tsx
@@ -0,0 +1,135 @@
+import React from 'react'
+import { render, fireEvent } from '@testing-library/react'
+import DiagnosisForm from './DiagnosisForm'
+import * as data from './DiagnosisFields.json'
+
+/*
+
+Diagnosis Fields are stored in DiagnosisFields.json in the format:
+
+{
+    "diagnoses" : [
+        {
+            "name": "Name",
+            "id": "id",
+            "text-input-title": "Title",
+            "text-input-type": "type" (i.e. number)
+            "group-title": "Group Title",
+            "group": [
+                { "name": "Name1", "id": "id1" },
+                { "name": "Name2", "id": "id2" }
+            ]
+        },
+        {...}
+    ]
+}
+*/
+
+const diagnosisFields = data.diagnoses
+
+test('renders the form', async () => {
+    const dom = render(<DiagnosisForm />)
+    expect(dom.getByTestId('diagnosis-form-wrapper')).toBeTruthy()
+})
+
+test('renders each diagnoses.name data field', () => {
+    const { getByText } = render(<DiagnosisForm />)
+
+    diagnosisFields.forEach((diagnosis) => {
+        if (diagnosis.name != null) {
+            const re = new RegExp(diagnosis.name, 'gi')
+            const field = getByText(re)
+            expect(field).toBeInTheDocument()
+        }
+    })
+})
+
+test(' each diagnoses.name has a corresponding checkbox and is able to be checked/unchecked', () => {
+    const { getByTestId } = render(<DiagnosisForm />)
+    diagnosisFields.forEach((diagnosis) => {
+        if (diagnosis.name != null && diagnosis.id != null) {
+            const re = new RegExp(diagnosis.id, 'gi')
+            const checkboxItem = getByTestId(re)
+            expect(checkboxItem).toHaveClass('am-checkbox-item')
+
+            const checkBox = checkboxItem.getElementsByTagName('span')[0]
+            expect(checkBox).not.toHaveClass('am-checkbox-checked')
+            const checkBoxInput = checkboxItem.getElementsByClassName(
+                'am-checkbox-input',
+            )[0]
+            fireEvent.click(checkBoxInput)
+            expect(checkBox).toHaveClass('am-checkbox-checked')
+        }
+    })
+})
+
+test('renders each diagnoses.text-input-title data field as a text entry field', () => {
+    const { getByTestId } = render(<DiagnosisForm />)
+
+    diagnosisFields.forEach((diagnosis) => {
+        if (
+            diagnosis['text-input-title'] != null &&
+            diagnosis['text-input-title'] != null
+        ) {
+            const re = new RegExp(diagnosis['text-input-id'], 'gi')
+            const field = getByTestId(re)
+            expect(field).toBeInTheDocument()
+            expect(field).toHaveAttribute('type', 'text')
+        }
+    })
+})
+
+test('renders each diagnoses.group-title data field as a header', () => {
+    const { getByText } = render(<DiagnosisForm />)
+    diagnosisFields.forEach((diagnosis) => {
+        if (diagnosis['group-title'] != null && diagnosis.group != null) {
+            const re = new RegExp(`\^${diagnosis['group-title']}\$`, 'gi')
+            const field = getByText(re)
+            expect(field).toBeInTheDocument()
+            expect(field).toHaveClass('am-list-header')
+        }
+    })
+})
+
+test('renders each diagnoses.group entry in the same list element', () => {
+    const { getByTestId } = render(<DiagnosisForm />)
+    diagnosisFields.forEach((diagnosis) => {
+        if (diagnosis.group != null && diagnosis.id != null) {
+            // get the list by diagnosis.id
+            const re = new RegExp(`\^${diagnosis.id}\$`, 'gi')
+            const field = getByTestId(re)
+            expect(field).toBeInTheDocument()
+            expect(field).toHaveClass('am-list')
+
+            // For each element in the group, ensure it is contained in the list
+            diagnosis.group.forEach((groupElement) => {
+                const el = getByTestId(groupElement.id)
+                expect(field).toContainElement(el)
+            })
+        }
+    })
+})
+
+test('renders each diagnoses.[el] as a checkbox that can be checked/unchecked', () => {
+    const { getByTestId } = render(<DiagnosisForm />)
+    diagnosisFields.forEach((diagnosis) => {
+        if (diagnosis.group != null) {
+            diagnosis.group.forEach((groupElement) => {
+                const re = new RegExp(groupElement.id, 'gi')
+                const groupCheckboxItem = getByTestId(re)
+                expect(groupCheckboxItem).toBeInTheDocument()
+                expect(groupCheckboxItem).toHaveClass('am-checkbox-item')
+
+                const checkBox = groupCheckboxItem.getElementsByTagName(
+                    'span',
+                )[0]
+                expect(checkBox).not.toHaveClass('am-checkbox-checked')
+                const checkBoxInput = groupCheckboxItem.getElementsByClassName(
+                    'am-checkbox-input',
+                )[0]
+                fireEvent.click(checkBoxInput)
+                expect(checkBox).toHaveClass('am-checkbox-checked')
+            })
+        }
+    })
+})
diff --git a/pwa/src/components/DiagnosisForm.tsx b/pwa/src/components/DiagnosisForm.tsx
new file mode 100644
index 0000000..a242d96
--- /dev/null
+++ b/pwa/src/components/DiagnosisForm.tsx
@@ -0,0 +1,117 @@
+import React, { ReactElement } from 'react'
+import { List, Checkbox, InputItem, WhiteSpace } from 'antd-mobile'
+import '../scss/DiagnosisForm.scss'
+import * as data from './DiagnosisFields.json'
+
+/*
+
+Diagnosis Fields are stored in DiagnosisFields.json in the format:
+
+{
+    "diagnoses" : [
+        {
+            "name": "Name",
+            "id": "id",
+            "text-input-title": "Title",
+            "text-input-id": "id" for `id` and `data-testid` attributes
+            "text-input-type": "type" (i.e. number)
+            "max-length": 3
+            "group-title": "Group Title",
+            "group": [
+                { "name": "Name1", "id": "id1" },
+                { "name": "Name2", "id": "id2" }
+            ]
+        },
+        {...}
+    ]
+}
+*/
+
+const CheckboxItem = Checkbox.CheckboxItem
+const diagnosisFields = data.diagnoses
+
+export default function DiagnosisForm(): ReactElement {
+    return (
+        <div id="diagnosis-form-wrapper" data-testid="diagnosis-form-wrapper">
+            {diagnosisFields.map((field) => {
+                const formElements: ReactElement[] = []
+
+                if (field.name != null) {
+                    formElements.push(
+                        <List>
+                            <CheckboxItem
+                                id={field.id}
+                                data-testid={field.id}
+                                key={field.id}
+                            >
+                                {field.name}
+                            </CheckboxItem>
+                        </List>,
+                    )
+                }
+
+                if (
+                    field['text-input-title'] != null &&
+                    field['text-input-id'] != null
+                ) {
+                    formElements.push(
+                        <List renderHeader={() => field['text-input-title']}>
+                            <InputItem
+                                id={field['text-input-id']}
+                                data-testid={field['text-input-id']}
+                                key={field['text-input-id']}
+                                type={
+                                    field['text-input-type'] === 'number'
+                                        ? 'number'
+                                        : 'text'
+                                }
+                                maxLength={
+                                    field['max-length']
+                                        ? field['max-length']
+                                        : null
+                                }
+                            />
+                        </List>,
+                    )
+                }
+
+                if (field.group != null) {
+                    const groupElements: ReactElement[] = []
+
+                    // add each group element to the internalElement array
+                    field.group.forEach((ele: any) => {
+                        if (ele.id != null && ele.name != null) {
+                            groupElements.push(
+                                <CheckboxItem
+                                    id={ele.id}
+                                    data-testid={ele.id}
+                                    key={ele.id}
+                                >
+                                    {ele.name}
+                                </CheckboxItem>,
+                            )
+                        }
+                    })
+
+                    // Render the entire list with the internal elements
+                    if (field['group-title'] != null && field.id !== null) {
+                        formElements.push(
+                            <List
+                                renderHeader={() => field['group-title']}
+                                data-testid={field.id}
+                            >
+                                {groupElements}
+                                <WhiteSpace
+                                    className="list-whitespace"
+                                    size="lg"
+                                />
+                            </List>,
+                        )
+                    }
+                }
+
+                return <> {formElements} </>
+            })}
+        </div>
+    )
+}
diff --git a/pwa/src/scss/DiagnosisForm.scss b/pwa/src/scss/DiagnosisForm.scss
new file mode 100644
index 0000000..3ee4ed2
--- /dev/null
+++ b/pwa/src/scss/DiagnosisForm.scss
@@ -0,0 +1,5 @@
+#diagnosis-form-wrapper {
+    .list-whitespace {
+        background-color: #f5f5f9;
+    }
+}