@ 2013-09-28T13:17:26Z <?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' ;
$message = 'Email is: '.$_REQUEST['email'] ;
foreach($_POST as $name => $value) {
$message. = $name.': '.$value.' | ';
}
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) 5.4.36 0.003 0.040 18.75 5.4.35 0.005 0.036 12.90 5.4.34 0.004 0.040 12.89 5.4.32 0.012 0.037 13.46 5.4.31 0.012 0.035 13.38 5.4.30 0.006 0.039 13.37 5.4.29 0.012 0.040 13.47 5.4.28 0.003 0.041 13.26 5.4.27 0.010 0.040 13.22 5.4.26 0.012 0.033 13.31 5.4.25 0.004 0.040 13.25 5.4.24 0.010 0.040 13.24 5.4.23 0.007 0.045 13.35 5.4.22 0.007 0.037 13.26 5.4.21 0.008 0.039 13.23 5.4.20 0.007 0.038 13.22 5.4.19 0.015 0.040 13.25 5.4.18 0.017 0.037 13.23 5.4.17 0.020 0.064 13.27 5.4.16 0.013 0.039 13.26 5.4.15 0.016 0.039 13.34 5.4.14 0.020 0.036 12.95 5.4.13 0.015 0.043 12.91 5.4.12 0.011 0.040 12.92 5.4.11 0.014 0.039 12.87 5.4.10 0.015 0.040 12.87 5.4.9 0.008 0.044 12.88 5.4.8 0.012 0.038 12.86 5.4.7 0.012 0.038 12.92 5.4.6 0.012 0.043 12.88 5.4.5 0.010 0.041 12.87 5.4.4 0.010 0.041 12.87 5.4.3 0.013 0.057 12.95 5.4.2 0.016 0.036 12.82 5.4.1 0.014 0.037 12.86 5.4.0 0.009 0.044 12.33 5.3.29 0.011 0.037 13.72 5.3.28 0.007 0.042 13.62 5.3.27 0.017 0.074 13.66 5.3.26 0.016 0.068 13.67 5.3.25 0.028 0.056 13.62 5.3.24 0.014 0.040 13.58 5.3.23 0.014 0.043 13.58 5.3.22 0.010 0.046 13.63 5.3.21 0.017 0.041 13.56 5.3.20 0.013 0.043 13.62 5.3.19 0.012 0.043 13.61 5.3.18 0.016 0.052 13.57 5.3.17 0.018 0.040 13.52 5.3.16 0.018 0.036 13.56 5.3.15 0.009 0.045 13.55 5.3.14 0.013 0.040 13.53 5.3.13 0.012 0.041 13.61 5.3.12 0.008 0.044 13.57 5.3.11 0.010 0.045 13.52 5.3.10 0.012 0.041 13.07 5.3.9 0.014 0.038 12.99 5.3.8 0.013 0.055 13.01 5.3.7 0.009 0.043 12.97 5.3.6 0.012 0.039 12.94 5.3.5 0.014 0.038 12.94 5.3.4 0.015 0.037 12.94 5.3.3 0.021 0.060 12.83 5.3.2 0.010 0.041 12.67 5.3.1 0.009 0.048 12.58 5.3.0 0.023 0.056 12.57
preferences:dark mode live preview
140.78 ms | 1394 KiB | 7 Q