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medical_form.php
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<!doctype html>
<html lang="en">
<head>
<!-- Required meta tags -->
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<!-- Bootstrap CSS -->
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/5.0.0-alpha2/css/bootstrap.min.css" integrity="sha384-DhY6onE6f3zzKbjUPRc2hOzGAdEf4/Dz+WJwBvEYL/lkkIsI3ihufq9hk9K4lVoK" crossorigin="anonymous">
<link rel = "icon" href = "images/icon.png" type = "image/x-icon">
<title>Medi Assist</title>
<style>
.image{
position: sticky;
top: 4vh;
filter: hue-rotate(60deg);
box-shadow: 0 0 8px 8px white inset;
}
</style>
</head>
<body>
<nav class="navbar navbar-light bg-light">
<div class="container-fluid border-dark border-bottom">
<a class="navbar-brand" href="#">
<img src="images/icon.png" alt="" width="50" height="50" class="d-inline-block align-top">
<span class="h1">MediAssist</span>
</a>
</div>
</nav>
<div class="container-fluid">
<div class="row justify-content-center">
<p class="h3 m-0 text-center">Medical Information Form</p>
<p class="m-0 text-center">(This will help us to serve you better)</p>
</div>
<div class="row bg-light">
<div class="col-8">
<div class="row col-4 pt-5 pb-2">
<div class="input-group input-group-lg">
<span class="input-group-text" id="inputGroup-sizing-lg">User Id</span>
<input type="text" class="form-control" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-lg" disabled>
</div>
</div>
<div class="row p-4">
<div class="row h4 border-bottom border-dark d-inline-block">Personal Information<span class="p-1" style="color: red;">*</span></div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">First Name<span style="color: red;">*</span></span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default" readonly>
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Last Name<span style="color: red;">*</span></span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default" readonly>
</div>
</div>
</div>
<div class="row">
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">D.O.B<span style="color: red;">*</span></span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-2">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Age<span style="color: red;">*</span></span>
<input type="number" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default" min="0" max="110" required>
</div>
</div>
<div class="col-3 d-flex">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Gender<span style="color: red;">*</span></span>
<input type="radio" class="btn-check" name="options-outlined" id="male-outlined" autocomplete="off" required>
<label class="btn btn-outline-success ml-1 p-1" for="male-outlined">Male</label>
<input type="radio" class="btn-check" name="options-outlined" id="female-outlined" autocomplete="off" required>
<label class="btn btn-outline-success ml-1 p-1" for="female-outlined">Female</label>
</div>
</div>
<div class="col-3 d-flex">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Blood Group<span style="color: red;">*</span></span>
<select class="form-select" aria-label="Default select example">
<option value="O+" selected>O+</option>
<option value="A+">A+</option>
<option value="B+">B+</option>
<option value="AB+">AB+</option>
<option value="A-">A-</option>
<option value="B-">B-</option>
<option value="O-">O-</option>
<option value="AB-">AB-</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Aadhar Card Number</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
</div>
<div class="row p-4">
<div class="row h4 border-bottom border-dark">Medical Check</div>
<div class="row">
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Heart Rate</span>
<input type="number" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default" min="45" max="125" required>
<span class="input-group-text" id="inputGroup-sizing-default"><small>in bpm</small></span>
</div>
</div>
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Diabetes</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Blood Pressure</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Arthritis</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Any Allergy</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
<div class="col-4">
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default" placeholder="If YES, What kind of allergy you have?">
</div>
</div>
<div class="row">
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Asthma</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
</div>
</div>
<div class="row p-4">
<div class="row h4 border-bottom border-dark">Habits</div>
<div class="row">
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Smoking</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Alcohol Consumption</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
<div class="col-4">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Regular Exercise</span>
<select class="form-select" aria-label="Default select example">
<option value="NO" selected>No</option>
<option value="YES">Yes</option>
</select>
</div>
</div>
</div>
</div>
<div class="row p-4">
<div class="row h4 border-bottom border-dark">Surgeries and Dates</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">1<sup>st</sup> Surgery</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of 1<sup>st</sup> Surgery</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">2<sup>nd</sup> Surgery</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of 2<sup>nd</sup> Surgery</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">3<sup>rd</sup> Surgery</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of 3<sup>rd</sup> Surgery</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="mb-3">
<label for="exampleFormControlTextarea1" class="form-label">Any Additional Information</label>
<textarea class="form-control" id="exampleFormControlTextarea1" rows="3"></textarea>
</div>
</div>
</div>
<div class="row p-4">
<div class="row h4 border-bottom border-dark">Doctors Consulted</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">1<sup>st</sup> Doctor's Name</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of Consultantion</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Purpose of Consultation</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">2<sup>nd</sup> Doctor's Name</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of Consultantion</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Purpose of Consultation</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">3<sup>rd</sup> Doctor's Name</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
<div class="col-6">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Date of Consultantion</span>
<input type="date" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="input-group mb-3">
<span class="input-group-text" id="inputGroup-sizing-default">Purpose of Consultation</span>
<input type="text" class="form-control col-6" aria-label="Sizing example input" aria-describedby="inputGroup-sizing-default">
</div>
</div>
</div>
<div class="row">
<div class="mb-3">
<label for="exampleFormControlTextarea1" class="form-label">Any Additional Information</label>
<textarea class="form-control" id="exampleFormControlTextarea1" rows="3"></textarea>
</div>
</div>
</div>
<div class="row p-5">
<!-- <button type="submit" class="btn btn-success btn-lg">Submit Medical Details</button> -->
<a href="menu.php" class="btn btn-success btn-lg" type="submit" role="button">Submit Medical Details</a>
</div>
</div>
<div class="col-4">
<img class="image border-left border-dark p-2" src="Images/medical_report.jpg" alt="">
</div>
</div>
</div>
<!-- Optional JavaScript; choose one of the two! -->
<!-- Option 1: Bootstrap Bundle with Popper.js -->
<script src="https://stackpath.bootstrapcdn.com/bootstrap/5.0.0-alpha2/js/bootstrap.bundle.min.js" integrity="sha384-BOsAfwzjNJHrJ8cZidOg56tcQWfp6y72vEJ8xQ9w6Quywb24iOsW913URv1IS4GD" crossorigin="anonymous"></script>
<!-- Option 2: Separate Popper.js and Bootstrap JS
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/umd/popper.min.js" integrity="sha384-9/reFTGAW83EW2RDu2S0VKaIzap3H66lZH81PoYlFhbGU+6BZp6G7niu735Sk7lN" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/5.0.0-alpha2/js/bootstrap.min.js" integrity="sha384-5h4UG+6GOuV9qXh6HqOLwZMY4mnLPraeTrjT5v07o347pj6IkfuoASuGBhfDsp3d" crossorigin="anonymous"></script>
-->
</body>
</html>