@ 2013-09-28T13:20:57Z <?php
require_once('config.php');
//Page Title
$pagetitle='Forms - '.$sitename;
//active menu item
$active="contact";
/*
$description=' Whatever you want';
$metakeywords'keyword1,2,2 etc';
*/
$form=$_GET['form'];
if($form=='1'){
$pagetitle='Assessment Form - '.$sitename;
$styles='select { width:100px; float:right;} .btn-submit {background:#ccc;} .sfield { margin-bottom:10px; border-bottom:1px solid #ddd;overflow: hidden;padding: 10px;}';
require_once('header.php');
?>
<h1>Assessment for Admission</h1>
<?php if($_POST){
//send email
$email = $_REQUEST['email'] ;
$subject = 'Noble Care Assessment Entry' ;
foreach($_POST as $name => $value) {
$message1 = $name.': '.$value.' | ';
}
$message = 'Email is: '.$_REQUEST['email'].'&&& '.$message1;
mail("osamaejaz1@gmail.com,info@mynoblecare.com", $subject,
$message, "From:" . $email);
echo '<h2>Thank You!</h2><p style="margin-left:20px;">Your Assessment form is sent. You will be replied soon.</p>';
}
} else { ?>
<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-bottom: 20px;margin-left: -120px;">Patient Name: <br/><input style="position: relative;left: 80px;" type="text" class="input" placeholder="Patient's name" /><br/><br/></div>
<div class="sfield">
General Health Status:
<select name="general-health-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Physical Fitness:
<select name="physical-fitness">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="good">Good</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">Social behavior:
<select name="social-behavior">
<option>Select:</option>
<option value="friendly">Friendly</option>
<option value="indifferent">Indifferent</option>
<option value="agitated">Agitated</option>
<option value="aggressive">Aggressive</option>
</select>
</div>
<div class="sfield">Mobility & Body Movements:
<select name="movement">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="restricted">Restricted</option>
<option value="with-support">Move with Support</option>
<option value="total-bed-ridden">Total Bed Ridden</option>
</select>
</div>
<div class="sfield">
Speech & Communication:
<select name="speech-and-communication">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="poor">Poor</option>
<option value="least-understand">Least Understand</option>
<option value="cannot-speak">Cannot Speak</option>
</select>
</div>
<div class="sfield">
Interpersonal Relations:
<select name="interpersonal-relations">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="good">Good</option>
<option value="poor">Poor</option>
<option value="verypoor">Very Poor</option>
</select>
</div>
<div class="sfield">
Level of Understanding:
<select name="understanding">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="poor">Poor</option>
<option value="weak">Weak</option>
</select>
</div>
<div class="sfield">
Learning Ability and Memory:
<select name="learning-and-memory">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Vision (Eye Sight):
<select name="vision-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Hearing Level:
<select name="hearing-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Health Condition:
<select name="health-condition">
<option>Select:</option>
<option value="good">Good</option>
<option value="minor-ill">Minor ill</option>
<option value="major-illness">Major illness</option>
<option value="terminal">Terminal</option>
</select>
</div>
<div class="sfield">
Wounds, Bed Sores etc:
<select name="wounds-status">
<option>Select:</option>
<option value="nil">Nil</option>
<option value="small">Small</option>
<option value="large">Large</option>
<option value="many">Many</option>
</select>
</div>
<div class="sfield">
Feeding and Drinking:
<select name="feeding-drinking-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="assisted">Assisted</option>
<option value="no-self-feeding">No Self-Feed</option>
<option value="ng-tube">N G TUBE</option>
</select>
</div>
<div class="sfield">
Urine:
<select name="urine-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="frequent">Frequent</option>
<option value="uncontrolled">Uncontrolled</option>
<option value="catheter">Catheter</option>
</select>
</div>
<div class="sfield">
Motion/Stool/Bowel:
<select name="motion-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="frequent">Frequent</option>
<option value="uncontrolled">Uncontrolled</option>
<option value="pampered">Pampered</option>
</select>
</div>
<div class="sfield">
Previous Admissions:
<select name="previous-admission-status">
<option>Select:</option>
<option value="nil">Nil</option>
<option value="oldfolks-home">Old Folks Home</option>
<option value="nursing-home">Nursing Home</option>
<option value="hospital">Hospital</option>
</select>
</div>
<div class="sfield">
General Self Care:
<select name="general-self-care">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="nil">Nil</option>
</select>
</div>
<input type="submit" value="Submit" style="margin-left: 160px;width:200px;" class="btn-submit" />
</form>
<?php
}
} else {
header("Location: /not-found");
}
?>
<?php
require_once('sidebar.php');
require_once('footer.php');
?>
Enable javascript to submit You have javascript disabled. You will not be able to edit any code.
Here you find the average performance (time & memory) of each version. A grayed out version indicates it didn't complete successfully (based on exit-code).
Version System time (s) User time (s) Memory (MiB) 5.5.4 0.383 0.040 19.38 5.5.3 0.343 0.043 19.45 5.5.2 0.447 0.030 19.36 5.5.1 0.357 0.037 19.40 5.5.0 0.320 0.040 19.41 5.4.20 0.403 0.033 18.98 5.4.19 0.407 0.033 18.86 5.4.18 0.357 0.037 19.09 5.4.17 0.360 0.033 19.04 5.4.16 0.347 0.037 19.06 5.4.15 0.337 0.033 19.01 5.4.14 0.197 0.037 16.41 5.4.13 0.010 0.073 16.57 5.4.12 0.423 0.037 16.36 5.4.11 0.410 0.037 16.35 5.4.10 0.423 0.040 16.48 5.4.9 0.390 0.033 16.42 5.4.8 0.363 0.027 16.47 5.4.7 0.343 0.033 16.47 5.4.6 0.337 0.040 16.29 5.4.5 0.357 0.033 16.36 5.4.4 0.363 0.037 16.50 5.4.3 0.367 0.037 16.35 5.4.2 0.407 0.037 16.32 5.4.1 0.360 0.030 16.46 5.4.0 0.313 0.033 16.02 5.3.27 0.353 0.040 14.58 5.3.26 0.327 0.040 14.58 5.3.25 0.320 0.033 14.60 5.3.24 0.007 0.073 14.36 5.3.23 0.010 0.040 14.44 5.3.22 0.420 0.037 14.57 5.3.21 0.417 0.033 14.41 5.3.20 0.393 0.040 14.44 5.3.19 0.333 0.033 14.55 5.3.18 0.360 0.037 14.49 5.3.17 0.373 0.037 14.66 5.3.16 0.360 0.040 14.52 5.3.15 0.340 0.033 14.57 5.3.14 0.387 0.033 14.65 5.3.13 0.360 0.040 14.55 5.3.12 0.380 0.037 14.52 5.3.11 0.417 0.040 14.49 5.3.10 0.323 0.040 14.02 5.3.9 0.333 0.027 13.98 5.3.8 0.330 0.037 13.96 5.3.7 0.330 0.040 13.98 5.3.6 0.383 0.040 13.99 5.3.5 0.340 0.040 13.82 5.3.4 0.323 0.040 13.89 5.3.3 0.343 0.040 13.88 5.3.2 0.353 0.030 13.63 5.3.1 0.383 0.033 13.59 5.3.0 0.410 0.033 13.59
preferences:dark mode live preview
136.41 ms | 1394 KiB | 7 Q