@ 2013-09-30T18:38:51Z <?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';
$message .='Score - alternative calculation: '.$message1n-68.' out of 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');
?>
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) 5.4.20 0.005 0.039 12.39 5.4.19 0.018 0.042 12.37 5.4.18 0.015 0.043 12.37 5.4.17 0.010 0.048 12.38 5.4.16 0.017 0.042 12.37 5.4.15 0.018 0.044 12.36 5.4.14 0.020 0.068 12.06 5.4.13 0.019 0.043 12.04 5.4.12 0.015 0.041 12.00 5.4.11 0.014 0.043 12.00 5.4.10 0.015 0.043 12.00 5.4.9 0.016 0.041 12.01 5.4.8 0.017 0.040 12.01 5.4.7 0.016 0.040 12.00 5.4.6 0.017 0.070 12.00 5.4.5 0.018 0.039 12.00 5.4.4 0.017 0.039 11.98 5.4.3 0.016 0.042 11.98 5.4.2 0.017 0.040 11.98 5.4.1 0.012 0.044 11.99 5.4.0 0.014 0.041 11.48 5.3.27 0.020 0.073 12.72 5.3.26 0.018 0.046 12.72 5.3.25 0.029 0.092 12.72 5.3.24 0.016 0.047 12.71 5.3.23 0.017 0.048 12.71 5.3.22 0.016 0.049 12.68 5.3.21 0.033 0.090 12.68 5.3.20 0.016 0.046 12.68 5.3.19 0.022 0.041 12.68 5.3.18 0.024 0.036 12.68 5.3.17 0.013 0.049 12.67 5.3.16 0.019 0.041 12.68 5.3.15 0.009 0.050 12.68 5.3.14 0.018 0.041 12.66 5.3.13 0.021 0.039 12.66 5.3.12 0.012 0.048 12.66 5.3.11 0.046 0.076 12.66 5.3.10 0.010 0.052 12.12 5.3.9 0.021 0.037 12.08 5.3.8 0.014 0.045 12.07 5.3.7 0.015 0.044 12.08 5.3.6 0.014 0.045 12.06 5.3.5 0.013 0.047 12.00 5.3.4 0.014 0.045 12.00 5.3.3 0.019 0.070 11.94 5.3.2 0.012 0.046 11.71 5.3.1 0.014 0.042 11.68 5.3.0 0.018 0.039 11.66
preferences:dark mode live preview
137.26 ms | 1398 KiB | 7 Q