<?php
require_once('config.php');
//Page Title
$pagetitle='Forms - '.$sitename;
//active menu item
$active="forms";
if($_GET['form']){
$subactive="assessment-form";
}
/*
$description=' Whatever you want';
$metakeywords'keyword1,2,2 etc';
*/
$styles='.fms { width:600px !important;opacity:1 !important; border:2px solid #ccc;}';
$form=$_GET['form'];
if($form=='1'){
$pagetitle='Assessment Form - '.$sitename;
$styles .='.h2 {margin-left: 10px;} select { width:100px; float:right;} .btn-submit {background:#ccc;} .sfield { margin-bottom:10px; border-bottom:1px solid #ddd;overflow: hidden;padding: 10px;}';
require_once('header.php');
?>
<h1>Assessment for Admission</h1>
<?php if($_POST){
//send email
$email = $_REQUEST['email'] ;
$subject = 'Noble Care Assessment Entry' ;
foreach($_POST as $name => $value) {
$message1 .= $name;
$message1 .=': '.$value.' | ';
if(!$message1n){
$message1n = $value;
} else {
$message1n = $message1n+$value;
}
}
$message = 'Patient Name: '.$_POST['pt-name'].'
Email: '.$email.'
Name: '.$_POST['sender-fullname'].'
Score: '.$message1n.' / 68
';
$message .='Score - alternative calculation: '.$message1n-68.' / 68';
$message .='Raw Values: '.$message1;
mail("osamaejaz1@gmail.com,info@mynoblecare.com", $subject,
$message, "From:" . $email);
echo '<h2 class="h2">Thank You!</h2><p style="margin-left:20px;">Your Assessment form is sent. You will be replied soon.</p>';
} else { ?>
<h2 class="h2">Please fill out the following form.</h2>
<br/>
<form style="overflow: hidden;padding: 50px;background: rgba(255,255,255,.4);border-radius: 20px;-moz-border-radius: 20px;-webkit-border-radius: 20px;border: 1px solid #ccc;" method="POST" action="">
<div style="text-align: center;margin-left: -145px;">Patient Name: <br/><input name="pt-name" style="position: relative;left: 80px;" type="text" class="input" placeholder="Patient's name" /><br/><br/></div>
<div style="padding:20px;border-bottom:2px solid #ddd;overflow: hidden;padding-bottom: 0;padding-top: 0;">
<div style="float:left;">Fullname: <br/><input name="sender-fullname" style="position: relative;" type="text" class="input" placeholder="Your Fullname" /><br/><br/></div>
<div style="float:right;">Your Email: <br/><input name="email" style="position: relative;" type="text" class="input" placeholder="Your Email" /><br/><br/></div>
</div>
<div class="sfield">
General Health Status:
<select name="general-health-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Weak</option>
<option value="4">Very Weak</option>
</select>
</div>
<div class="sfield">
Physical Fitness:
<select name="physical-fitness">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Good</option>
<option value="3">Weak</option>
<option value="4">Very Weak</option>
</select>
</div>
<div class="sfield">Social behavior:
<select name="social-behavior">
<option>Select:</option>
<option value="1">Friendly</option>
<option value="2">Indifferent</option>
<option value="3">Agitated</option>
<option value="4">Aggressive</option>
</select>
</div>
<div class="sfield">Mobility & Body Movements:
<select name="movement">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Restricted</option>
<option value="3">Move with Support</option>
<option value="4">Total Bed Ridden</option>
</select>
</div>
<div class="sfield">
Speech & Communication:
<select name="speech-and-communication">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Poor</option>
<option value="3">Least Understand</option>
<option value="4">Cannot Speak</option>
</select>
</div>
<div class="sfield">
Interpersonal Relations:
<select name="interpersonal-relations">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Good</option>
<option value="3">Poor</option>
<option value="4">Very Poor</option>
</select>
</div>
<div class="sfield">
Level of Understanding:
<select name="understanding">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Poor</option>
<option value="4">Weak</option>
</select>
</div>
<div class="sfield">
Learning Ability and Memory:
<select name="learning-and-memory">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Weak</option>
<option value="4">Very Weak</option>
</select>
</div>
<div class="sfield">
Vision (Eye Sight):
<select name="vision-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Weak</option>
<option value="4">Very Weak</option>
</select>
</div>
<div class="sfield">
Hearing Level:
<select name="hearing-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Weak</option>
<option value="4">Very Weak</option>
</select>
</div>
<div class="sfield">
Health Condition:
<select name="health-condition">
<option>Select:</option>
<option value="1">Good</option>
<option value="2">Minor ill</option>
<option value="3">Major illness</option>
<option value="4">Terminal</option>
</select>
</div>
<div class="sfield">
Wounds, Bed Sores etc:
<select name="wounds-status">
<option>Select:</option>
<option value="1">Nil</option>
<option value="2">Small</option>
<option value="3">Large</option>
<option value="4">Many</option>
</select>
</div>
<div class="sfield">
Feeding and Drinking:
<select name="feeding-drinking-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Assisted</option>
<option value="3">No Self-Feed</option>
<option value="4">N G TUBE</option>
</select>
</div>
<div class="sfield">
Urine:
<select name="urine-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Frequent</option>
<option value="3">Uncontrolled</option>
<option value="4">Catheter</option>
</select>
</div>
<div class="sfield">
Motion/Stool/Bowel:
<select name="motion-status">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Frequent</option>
<option value="3">Uncontrolled</option>
<option value="4">Pampered</option>
</select>
</div>
<div class="sfield">
Previous Admissions:
<select name="previous-admission-status">
<option>Select:</option>
<option value="1">Nil</option>
<option value="2">Old Folks Home</option>
<option value="3">Nursing Home</option>
<option value="4">Hospital</option>
</select>
</div>
<div class="sfield" style="margin-bottom:0;">
General Self Care:
<select name="general-self-care">
<option>Select:</option>
<option value="1">Normal</option>
<option value="2">Fair</option>
<option value="3">Weak</option>
<option value="4">Nil</option>
</select>
</div>
<div class="sfield" style="padding-top:0;">
<h2 style="margin-left:0;" class="h2">Any optional message:</h2>
<textarea style="height:100px;width:550px;display:block;" type="text" name="optional-msg" placeholder="Optional message..." class="textarea"></textarea>
</div>
<input type="submit" value="Submit" style="margin-left: 200px;width:200px;" class="btn-submit" />
</form>
<?php
}
} elseif(!$_GET['form']) {
$pagetitle="Forms - ".$sitename;
require_once('header.php');
echo '<h1>Forms</h1><p style="margin-left:20px;"><a href="/forms/assessment-form" title="Assessment Form"><img class="fms left" src="http://www.mynoblecare.com/thumber.php?img=images/stethoscope_assessment-form.png&h=200&w=300" alt="assessment form" /></a></p>';
} else {
header("Location: /not-found");
}
?>
<?php
require_once('sidebar.php');
require_once('footer.php');
?>
- Output for 5.4.0 - 5.4.20, 5.5.0 - 5.5.4
- Parse error: syntax error, unexpected '' / 68'' (T_CONSTANT_ENCAPSED_STRING) in /in/7oki4 on line 43
Process exited with code 255. - Output for 5.3.0 - 5.3.27
- Parse error: syntax error, unexpected T_CONSTANT_ENCAPSED_STRING in /in/7oki4 on line 43
Process exited with code 255.
preferences:
184.16 ms | 1395 KiB | 61 Q