Online PHP editor | vld for SmXf6

<?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; $message .='Score - alternative calculation: '.$message1n-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'); ?>

Finding entry points
Branch analysis from position: 0
2 jumps found. (Code = 43) Position 1 = 7, Position 2 = 8
Branch analysis from position: 7
2 jumps found. (Code = 43) Position 1 = 14, Position 2 = 69
Branch analysis from position: 14
2 jumps found. (Code = 43) Position 1 = 21, Position 2 = 67
Branch analysis from position: 21
2 jumps found. (Code = 77) Position 1 = 27, Position 2 = 40
Branch analysis from position: 27
2 jumps found. (Code = 78) Position 1 = 28, Position 2 = 40
Branch analysis from position: 28
2 jumps found. (Code = 43) Position 1 = 35, Position 2 = 37
Branch analysis from position: 35
1 jumps found. (Code = 42) Position 1 = 39
Branch analysis from position: 39
1 jumps found. (Code = 42) Position 1 = 27
Branch analysis from position: 27
Branch analysis from position: 37
1 jumps found. (Code = 42) Position 1 = 27
Branch analysis from position: 27
Branch analysis from position: 40
1 jumps found. (Code = 42) Position 1 = 68
Branch analysis from position: 68
1 jumps found. (Code = 42) Position 1 = 81
Branch analysis from position: 81
1 jumps found. (Code = 62) Position 1 = -2
Branch analysis from position: 40
Branch analysis from position: 67
1 jumps found. (Code = 42) Position 1 = 81
Branch analysis from position: 81
Branch analysis from position: 69
2 jumps found. (Code = 43) Position 1 = 73, Position 2 = 78
Branch analysis from position: 73
1 jumps found. (Code = 42) Position 1 = 81
Branch analysis from position: 81
Branch analysis from position: 78
1 jumps found. (Code = 62) Position 1 = -2
Branch analysis from position: 8
filename:       /in/SmXf6
function name:  (null)
number of ops:  84
compiled vars:  !0 = $pagetitle, !1 = $sitename, !2 = $active, !3 = $subactive, !4 = $styles, !5 = $form, !6 = $email, !7 = $subject, !8 = $value, !9 = $name, !10 = $message1, !11 = $message1n, !12 = $message
line      #* E I O op                           fetch          ext  return  operands
-------------------------------------------------------------------------------------
    2     0  E >   INCLUDE_OR_EVAL                                          'config.php', REQUIRE_ONCE
    5     1        CONCAT                                           ~14     'Forms+-+', !1
          2        ASSIGN                                                   !0, ~14
    8     3        ASSIGN                                                   !2, 'forms'
    9     4        FETCH_R                      global              ~17     '_GET'
          5        FETCH_DIM_R                                      ~18     ~17, 'form'
          6      > JMPZ                                                     ~18, ->8
   10     7    >   ASSIGN                                                   !3, 'assessment-form'
   16     8    >   ASSIGN                                                   !4, '.fms+%7B+width%3A600px+%21important%3Bopacity%3A1+%21important%3B+border%3A2px+solid+%23ccc%3B%7D'
   17     9        FETCH_R                      global              ~21     '_GET'
         10        FETCH_DIM_R                                      ~22     ~21, 'form'
         11        ASSIGN                                                   !5, ~22
   18    12        IS_EQUAL                                                 !5, '1'
         13      > JMPZ                                                     ~24, ->69
   19    14    >   CONCAT                                           ~25     'Assessment+Form+-+', !1
         15        ASSIGN                                                   !0, ~25
   20    16        ASSIGN_OP                                     8          !4, '.h2+%7Bmargin-left%3A+10px%3B%7D+select+%7B+width%3A100px%3B+float%3Aright%3B%7D+.btn-submit+%7Bbackground%3A%23ccc%3B%7D+.sfield+%7B+margin-bottom%3A10px%3B+border-bottom%3A1px+solid+%23ddd%3Boverflow%3A+hidden%3Bpadding%3A+10px%3B%7D'
   21    17        INCLUDE_OR_EVAL                                          'header.php', REQUIRE_ONCE
   23    18        ECHO                                                     '%3Ch1%3EAssessment+for+Admission%3C%2Fh1%3E%0A'
   24    19        FETCH_R                      global              ~29     '_POST'
         20      > JMPZ                                                     ~29, ->67
   26    21    >   FETCH_R                      global              ~30     '_REQUEST'
         22        FETCH_DIM_R                                      ~31     ~30, 'email'
         23        ASSIGN                                                   !6, ~31
   27    24        ASSIGN                                                   !7, 'Noble+Care+Assessment+Entry'
   28    25        FETCH_R                      global              ~34     '_POST'
         26      > FE_RESET_R                                       $35     ~34, ->40
         27    > > FE_FETCH_R                                       ~36     $35, !8, ->40
         28    >   ASSIGN                                                   !9, ~36
   29    29        ASSIGN_OP                                     8          !10, !9
   30    30        CONCAT                                           ~39     '%3A+', !8
         31        CONCAT                                           ~40     ~39, '+%7C+'
         32        ASSIGN_OP                                     8          !10, ~40
   31    33        BOOL_NOT                                         ~42     !11
         34      > JMPZ                                                     ~42, ->37
   32    35    >   ASSIGN                                                   !11, !8
         36      > JMP                                                      ->39
   34    37    >   ADD                                              ~44     !11, !8
         38        ASSIGN                                                   !11, ~44
   28    39    > > JMP                                                      ->27
         40    >   FE_FREE                                                  $35
   37    41        FETCH_R                      global              ~46     '_POST'
         42        FETCH_DIM_R                                      ~47     ~46, 'pt-name'
         43        CONCAT                                           ~48     'Patient+Name%3A+', ~47
         44        CONCAT                                           ~49     ~48, '%0AEmail%3A+'
   38    45        CONCAT                                           ~50     ~49, !6
         46        CONCAT                                           ~51     ~50, '%0AName%3A+'
   39    47        FETCH_R                      global              ~52     '_POST'
         48        FETCH_DIM_R                                      ~53     ~52, 'sender-fullname'
         49        CONCAT                                           ~54     ~51, ~53
         50        CONCAT                                           ~55     ~54, '%0AScore%3A+'
   40    51        CONCAT                                           ~56     ~55, !11
   37    52        ASSIGN                                                   !12, ~56
   42    53        SUB                                              ~58     !11, 68
         54        CONCAT                                           ~59     'Score+-+alternative+calculation%3A+', ~58
         55        ASSIGN_OP                                     8          !12, ~59
   45    56        CONCAT                                           ~61     'Raw+Values%3A+', !10
         57        ASSIGN_OP                                     8          !12, ~61
   46    58        INIT_FCALL                                               'mail'
         59        SEND_VAL                                                 'osamaejaz1%40gmail.com%2Cinfo%40mynoblecare.com'
         60        SEND_VAR                                                 !7
   47    61        SEND_VAR                                                 !12
         62        CONCAT                                           ~63     'From%3A', !6
         63        SEND_VAL                                                 ~63
         64        DO_ICALL                                                 
   49    65        ECHO                                                     '%3Ch2+class%3D%22h2%22%3EThank+You%21%3C%2Fh2%3E%3Cp+style%3D%22margin-left%3A20px%3B%22%3EYour+Assessment+form+is+sent.+You+will+be+replied+soon.%3C%2Fp%3E'
         66      > JMP                                                      ->68
   51    67    >   ECHO                                                     '%3Ch2+class%3D%22h2%22%3EPlease+fill+out+the+following+form.%3C%2Fh2%3E%0A%3Cbr%2F%3E%0A%3Cform+style%3D%22overflow%3A+hidden%3Bpadding%3A+50px%3Bbackground%3A+rgba%28255%2C255%2C255%2C.4%29%3Bborder-radius%3A+20px%3B-moz-border-radius%3A+20px%3B-webkit-border-radius%3A+20px%3Bborder%3A+1px+solid+%23ccc%3B%22+method%3D%22POST%22+action%3D%22%22%3E%0A%3Cdiv+style%3D%22text-align%3A+center%3Bmargin-left%3A+-145px%3B%22%3EPatient+Name%3A+%3Cbr%2F%3E%3Cinput+name%3D%22pt-name%22+style%3D%22position%3A+relative%3Bleft%3A+80px%3B%22+type%3D%22text%22+class%3D%22input%22+placeholder%3D%22Patient%27s+name%22+%2F%3E%3Cbr%2F%3E%3Cbr%2F%3E%3C%2Fdiv%3E%0A%3Cdiv+style%3D%22padding%3A20px%3Bborder-bottom%3A2px+solid+%23ddd%3Boverflow%3A+hidden%3Bpadding-bottom%3A+0%3Bpadding-top%3A+0%3B%22%3E%0A%3Cdiv+style%3D%22float%3Aleft%3B%22%3EFullname%3A+%3Cbr%2F%3E%3Cinput+name%3D%22sender-fullname%22+style%3D%22position%3A+relative%3B%22+type%3D%22text%22+class%3D%22input%22+placeholder%3D%22Your+Fullname%22+%2F%3E%3Cbr%2F%3E%3Cbr%2F%3E%3C%2Fdiv%3E%0A%3Cdiv+style%3D%22float%3Aright%3B%22%3EYour+Email%3A+%3Cbr%2F%3E%3Cinput+name%3D%22email%22+style%3D%22position%3A+relative%3B%22+type%3D%22text%22+class%3D%22input%22+placeholder%3D%22Your+Email%22+%2F%3E%3Cbr%2F%3E%3Cbr%2F%3E%3C%2Fdiv%3E%0A%3C%2Fdiv%3E%0A%0A%3Cdiv+class%3D%22sfield%22%3E%0AGeneral+Health+Status%3A+%0A%3Cselect+name%3D%22general-health-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Weak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0APhysical+Fitness%3A+%0A%3Cselect+name%3D%22physical-fitness%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Weak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3ESocial+behavior%3A+%0A%3Cselect+name%3D%22social-behavior%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3EFriendly%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EIndifferent%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EAgitated%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EAggressive%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3EMobility+%26amp%3B+Body+Movements%3A+%0A%3Cselect+name%3D%22movement%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3ERestricted%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EMove+with+Support%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3ETotal+Bed+Ridden%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E+%0ASpeech+%26+Communication%3A+%0A%3Cselect+name%3D%22speech-and-communication%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3ELeast+Understand%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3ECannot+Speak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AInterpersonal+Relations%3A+%0A%3Cselect+name%3D%22interpersonal-relations%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Poor%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0ALevel+of+Understanding%3A+%0A%3Cselect+name%3D%22understanding%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EWeak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0ALearning+Ability+and+Memory%3A+%0A%3Cselect+name%3D%22learning-and-memory%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Weak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AVision+%28Eye+Sight%29%3A+%0A%3Cselect+name%3D%22vision-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Weak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AHearing+Level%3A+%0A%3Cselect+name%3D%22hearing-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EVery+Weak%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AHealth+Condition%3A+%0A%3Cselect+name%3D%22health-condition%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EMinor+ill%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EMajor+illness%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3ETerminal%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AWounds%2C+Bed+Sores+etc%3A+%0A%3Cselect+name%3D%22wounds-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENil%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3ESmall%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3ELarge%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EMany%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AFeeding+and+Drinking%3A+%0A%3Cselect+name%3D%22feeding-drinking-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EAssisted%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3ENo+Self-Feed%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EN+G+TUBE%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AUrine%3A+%0A%3Cselect+name%3D%22urine-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFrequent%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EUncontrolled%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3ECatheter%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0AMotion%2FStool%2FBowel%3A+%0A%3Cselect+name%3D%22motion-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFrequent%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EUncontrolled%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EPampered%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22%3E%0APrevious++Admissions%3A+%0A%3Cselect+name%3D%22previous-admission-status%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENil%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EOld+Folks+Home%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3ENursing++Home%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3EHospital%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22+style%3D%22margin-bottom%3A0%3B%22%3E%0AGeneral+Self+Care%3A+%0A%3Cselect+name%3D%22general-self-care%22%3E%0A%3Coption%3ESelect%3A%3C%2Foption%3E%0A%3Coption+value%3D%221%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%222%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%223%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%224%22%3ENil%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%22+style%3D%22padding-top%3A0%3B%22%3E%0A%3Ch2+style%3D%22margin-left%3A0%3B%22+class%3D%22h2%22%3EAny+optional+message%3A%3C%2Fh2%3E%0A%3Ctextarea+style%3D%22height%3A100px%3Bwidth%3A550px%3Bdisplay%3Ablock%3B%22+type%3D%22text%22+name%3D%22optional-msg%22+placeholder%3D%22Optional+message...%22+class%3D%22textarea%22%3E%3C%2Ftextarea%3E%0A%3C%2Fdiv%3E%0A%0A%3Cinput+type%3D%22submit%22+value%3D%22Submit%22+style%3D%22margin-left%3A+200px%3Bwidth%3A200px%3B%22+class%3D%22btn-submit%22+%2F%3E%0A%3C%2Fform%3E%0A%0A%0A%0A%0A'
         68    > > JMP                                                      ->81
  242    69    >   FETCH_R                      global              ~65     '_GET'
         70        FETCH_DIM_R                                      ~66     ~65, 'form'
         71        BOOL_NOT                                         ~67     ~66
         72      > JMPZ                                                     ~67, ->78
  243    73    >   CONCAT                                           ~68     'Forms+-+', !1
         74        ASSIGN                                                   !0, ~68
  244    75        INCLUDE_OR_EVAL                                          'header.php', REQUIRE_ONCE
  245    76        ECHO                                                     '%3Ch1%3EForms%3C%2Fh1%3E%3Cp+style%3D%22margin-left%3A20px%3B%22%3E%3Ca+href%3D%22%2Fforms%2Fassessment-form%22+title%3D%22Assessment+Form%22%3E%3Cimg+class%3D%22fms+left%22+src%3D%22http%3A%2F%2Fwww.mynoblecare.com%2Fthumber.php%3Fimg%3Dimages%2Fstethoscope_assessment-form.png%26h%3D200%26w%3D300%22+alt%3D%22assessment+form%22+%2F%3E%3C%2Fa%3E%3C%2Fp%3E'
         77      > JMP                                                      ->81
  249    78    >   INIT_FCALL                                               'header'
         79        SEND_VAL                                                 'Location%3A+%2Fnot-found'
         80        DO_ICALL                                                 
  256    81    >   INCLUDE_OR_EVAL                                          'sidebar.php', REQUIRE_ONCE
  257    82        INCLUDE_OR_EVAL                                          'footer.php', REQUIRE_ONCE
  258    83      > RETURN                                                   1

Generated using Vulcan Logic Dumper, using php 8.0.0