@ 2013-09-30T18:34:56Z <?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: '.$message1n.' out of 68
Score (alternative calculation): '.$message1n-68.' out of 68
(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');
?>
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 0.007 0.050 17.20 5.5.3 0.010 0.043 17.22 5.5.2 0.000 0.043 17.32 5.5.1 0.013 0.073 17.19 5.5.0 0.003 0.077 17.15 5.4.20 0.003 0.080 19.09 5.4.19 0.007 0.037 18.88 5.4.18 0.007 0.077 19.02 5.4.17 0.013 0.040 19.04 5.4.16 0.010 0.070 19.01 5.4.15 0.010 0.037 19.00 5.4.14 0.010 0.043 16.30 5.4.13 0.010 0.070 16.32 5.4.12 0.003 0.077 16.30 5.4.11 0.007 0.067 16.46 5.4.10 0.000 0.043 16.45 5.4.9 0.010 0.030 16.49 5.4.8 0.003 0.047 16.31 5.4.7 0.003 0.037 16.39 5.4.6 0.003 0.037 16.38 5.4.5 0.000 0.080 16.23 5.4.4 0.010 0.047 16.49 5.4.3 0.007 0.037 16.37 5.4.2 0.007 0.060 16.32 5.4.1 0.003 0.073 16.32 5.4.0 0.010 0.043 15.90 5.3.27 0.010 0.060 14.69 5.3.26 0.007 0.040 14.55 5.3.25 0.010 0.033 14.57 5.3.24 0.007 0.073 14.58 5.3.23 0.007 0.063 14.53 5.3.22 0.003 0.067 14.39 5.3.21 0.003 0.077 14.51 5.3.20 0.007 0.073 14.65 5.3.19 0.003 0.050 14.55 5.3.18 0.007 0.047 14.54 5.3.17 0.010 0.033 14.52 5.3.16 0.010 0.063 14.54 5.3.15 0.007 0.077 14.50 5.3.14 0.010 0.070 14.40 5.3.13 0.003 0.080 14.63 5.3.12 0.020 0.043 14.34 5.3.11 0.007 0.070 14.50 5.3.10 0.013 0.067 13.90 5.3.9 0.007 0.073 13.98 5.3.8 0.000 0.080 13.80 5.3.7 0.017 0.060 13.79 5.3.6 0.003 0.080 13.76 5.3.5 0.003 0.057 13.71 5.3.4 0.007 0.053 13.92 5.3.3 0.007 0.033 13.88 5.3.2 0.007 0.033 13.66 5.3.1 0.007 0.060 13.42 5.3.0 0.003 0.077 13.61
preferences:dark mode live preview
144.72 ms | 1394 KiB | 7 Q