Online PHP editor | vld for leeGR

<?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; } } $message1n2=68-$message1n; $headers = "From: " . strip_tags($_POST['email']) . "\r\n"; $headers .= "Reply-To: ". strip_tags($_POST['email']) . "\r\n"; $headers .= "MIME-Version: 1.0\r\n"; $headers .= "Content-Type: text/html; charset=ISO-8859-1\r\n"; $styles='.fms { width:600px !important;opacity:1 !important; border:2px solid #ccc;}'; $pagetitle='Assessment Form Entry - '.$sitename; foreach($_POST as $name => $value) { $styles .='.'.$name.' .hl'.$value.' { border: 1px solid #F00;font-weight: bold;background: green;color: #fff;padding: 5px;}'; } $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;}'; $htmldb=' <h1>Form Data</h1> <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>'; $htmldb=str_replace('<select name','<div style="float:right;" class',$htmldb); $htmldb=str_replace('</div>','</div></div>',$htmldb); $htmldb=str_replace('</select>','',$htmldb); $htmldb = str_replace('value="','class="hl',$htmldb); $htmldb = str_replace('option','span',$htmldb); $htmldb=str_replace('<span>Select:</span>','',$htmldb); $htmldb=$htmldb.' <div style="border-top:1px solid #ccc;"> </div> '; mysql_query("INSERT INTO aforms (html) VALUES ('$htmldb')") or die(mysql_error()); $htmlq = mysql_query("SELECT * FROM aforms WHERE html='$htmldb' ORDER BY id DESC LIMIT 1") or die(mysql_error()); $html = mysql_fetch_array($htmlq); $link='<a href="http://www.mynoblecare.com/view_form.php?id='.$html['id'].'">View Form</a>'; $message .=' <html> <head> <title>Assessment Form Entry</title> <style> '.$styles.' </style> </head> <body> '; $message .=' Patient Name: '.$_POST['pt-name'].'<br/><br/> Sender Email: '.$email.'<br/><br/> Sender Name: '.$_POST['sender-fullname'].'<br/><br/> Score: '.$message1n.' out of 68<br/><br/> Score (alternative calculation): '.$message1n2.' out of 68<br/><br/> Optional Message: '.$_POST['optional-msg'].'<br/><br/> '.$link.'; $message .="<br/><br/> Raw Values: '.$message1.' </body> </html>'; mail("osamaejaz1@gmail.com,info@mynoblecare.com", $subject, $message, $headers); 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 = 182
Branch analysis from position: 14
2 jumps found. (Code = 43) Position 1 = 21, Position 2 = 180
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
2 jumps found. (Code = 77) Position 1 = 66, Position 2 = 74
Branch analysis from position: 66
2 jumps found. (Code = 78) Position 1 = 67, Position 2 = 74
Branch analysis from position: 67
1 jumps found. (Code = 42) Position 1 = 66
Branch analysis from position: 66
Branch analysis from position: 74
2 jumps found. (Code = 47) Position 1 = 122, Position 2 = 126
Branch analysis from position: 122
1 jumps found. (Code = 79) Position 1 = -2
Branch analysis from position: 126
2 jumps found. (Code = 47) Position 1 = 134, Position 2 = 138
Branch analysis from position: 134
1 jumps found. (Code = 79) Position 1 = -2
Branch analysis from position: 138
1 jumps found. (Code = 42) Position 1 = 181
Branch analysis from position: 181
1 jumps found. (Code = 42) Position 1 = 194
Branch analysis from position: 194
1 jumps found. (Code = 62) Position 1 = -2
Branch analysis from position: 74
Branch analysis from position: 40
Branch analysis from position: 180
1 jumps found. (Code = 42) Position 1 = 194
Branch analysis from position: 194
Branch analysis from position: 182
2 jumps found. (Code = 43) Position 1 = 186, Position 2 = 191
Branch analysis from position: 186
1 jumps found. (Code = 42) Position 1 = 194
Branch analysis from position: 194
Branch analysis from position: 191
1 jumps found. (Code = 62) Position 1 = -2
Branch analysis from position: 8
filename:       /in/leeGR
function name:  (null)
number of ops:  197
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 = $message1n2, !13 = $headers, !14 = $htmldb, !15 = $htmlq, !16 = $html, !17 = $link, !18 = $message
line      #* E I O op                           fetch          ext  return  operands
-------------------------------------------------------------------------------------
    2     0  E >   INCLUDE_OR_EVAL                                          'config.php', REQUIRE_ONCE
    5     1        CONCAT                                           ~20     'Forms+-+', !1
          2        ASSIGN                                                   !0, ~20
    8     3        ASSIGN                                                   !2, 'forms'
    9     4        FETCH_R                      global              ~23     '_GET'
          5        FETCH_DIM_R                                      ~24     ~23, 'form'
          6      > JMPZ                                                     ~24, ->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              ~27     '_GET'
         10        FETCH_DIM_R                                      ~28     ~27, 'form'
         11        ASSIGN                                                   !5, ~28
   18    12        IS_EQUAL                                                 !5, '1'
         13      > JMPZ                                                     ~30, ->182
   19    14    >   CONCAT                                           ~31     'Assessment+Form+-+', !1
         15        ASSIGN                                                   !0, ~31
   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              ~35     '_POST'
         20      > JMPZ                                                     ~35, ->180
   26    21    >   FETCH_R                      global              ~36     '_REQUEST'
         22        FETCH_DIM_R                                      ~37     ~36, 'email'
         23        ASSIGN                                                   !6, ~37
   27    24        ASSIGN                                                   !7, 'Noble+Care+Assessment+Entry'
   28    25        FETCH_R                      global              ~40     '_POST'
         26      > FE_RESET_R                                       $41     ~40, ->40
         27    > > FE_FETCH_R                                       ~42     $41, !8, ->40
         28    >   ASSIGN                                                   !9, ~42
   29    29        ASSIGN_OP                                     8          !10, !9
   30    30        CONCAT                                           ~45     '%3A+', !8
         31        CONCAT                                           ~46     ~45, '+%7C+'
         32        ASSIGN_OP                                     8          !10, ~46
   31    33        BOOL_NOT                                         ~48     !11
         34      > JMPZ                                                     ~48, ->37
   32    35    >   ASSIGN                                                   !11, !8
         36      > JMP                                                      ->39
   34    37    >   ADD                                              ~50     !11, !8
         38        ASSIGN                                                   !11, ~50
   28    39    > > JMP                                                      ->27
         40    >   FE_FREE                                                  $41
   37    41        SUB                                              ~52     68, !11
         42        ASSIGN                                                   !12, ~52
   39    43        INIT_FCALL                                               'strip_tags'
         44        FETCH_R                      global              ~54     '_POST'
         45        FETCH_DIM_R                                      ~55     ~54, 'email'
         46        SEND_VAL                                                 ~55
         47        DO_ICALL                                         $56     
         48        CONCAT                                           ~57     'From%3A+', $56
         49        CONCAT                                           ~58     ~57, '%0D%0A'
         50        ASSIGN                                                   !13, ~58
   40    51        INIT_FCALL                                               'strip_tags'
         52        FETCH_R                      global              ~60     '_POST'
         53        FETCH_DIM_R                                      ~61     ~60, 'email'
         54        SEND_VAL                                                 ~61
         55        DO_ICALL                                         $62     
         56        CONCAT                                           ~63     'Reply-To%3A+', $62
         57        CONCAT                                           ~64     ~63, '%0D%0A'
         58        ASSIGN_OP                                     8          !13, ~64
   41    59        ASSIGN_OP                                     8          !13, 'MIME-Version%3A+1.0%0D%0A'
   42    60        ASSIGN_OP                                     8          !13, 'Content-Type%3A+text%2Fhtml%3B+charset%3DISO-8859-1%0D%0A'
   44    61        ASSIGN                                                   !4, '.fms+%7B+width%3A600px+%21important%3Bopacity%3A1+%21important%3B+border%3A2px+solid+%23ccc%3B%7D'
   45    62        CONCAT                                           ~69     'Assessment+Form+Entry+-+', !1
         63        ASSIGN                                                   !0, ~69
   47    64        FETCH_R                      global              ~71     '_POST'
         65      > FE_RESET_R                                       $72     ~71, ->74
         66    > > FE_FETCH_R                                       ~73     $72, !8, ->74
         67    >   ASSIGN                                                   !9, ~73
   48    68        CONCAT                                           ~75     '.', !9
         69        CONCAT                                           ~76     ~75, '+.hl'
         70        CONCAT                                           ~77     ~76, !8
         71        CONCAT                                           ~78     ~77, '+%7B+border%3A+1px+solid+%23F00%3Bfont-weight%3A+bold%3Bbackground%3A+green%3Bcolor%3A+%23fff%3Bpadding%3A+5px%3B%7D'
         72        ASSIGN_OP                                     8          !4, ~78
   47    73      > JMP                                                      ->66
         74    >   FE_FREE                                                  $72
   52    75        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'
   54    76        ASSIGN                                                   !14, '%0A%3Ch1%3EForm+Data%3C%2Fh1%3E%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'
  224    77        INIT_FCALL                                               'str_replace'
         78        SEND_VAL                                                 '%3Cselect+name'
         79        SEND_VAL                                                 '%3Cdiv+style%3D%22float%3Aright%3B%22+class'
         80        SEND_VAR                                                 !14
         81        DO_ICALL                                         $82     
         82        ASSIGN                                                   !14, $82
  225    83        INIT_FCALL                                               'str_replace'
         84        SEND_VAL                                                 '%3C%2Fdiv%3E'
         85        SEND_VAL                                                 '%3C%2Fdiv%3E%3C%2Fdiv%3E'
         86        SEND_VAR                                                 !14
         87        DO_ICALL                                         $84     
         88        ASSIGN                                                   !14, $84
  226    89        INIT_FCALL                                               'str_replace'
         90        SEND_VAL                                                 '%3C%2Fselect%3E'
         91        SEND_VAL                                                 '%3C%21--+end+select+--%3E'
         92        SEND_VAR                                                 !14
         93        DO_ICALL                                         $86     
         94        ASSIGN                                                   !14, $86
  227    95        INIT_FCALL                                               'str_replace'
         96        SEND_VAL                                                 'value%3D%22'
         97        SEND_VAL                                                 'class%3D%22hl'
         98        SEND_VAR                                                 !14
         99        DO_ICALL                                         $88     
        100        ASSIGN                                                   !14, $88
  228   101        INIT_FCALL                                               'str_replace'
        102        SEND_VAL                                                 'option'
        103        SEND_VAL                                                 'span'
        104        SEND_VAR                                                 !14
        105        DO_ICALL                                         $90     
        106        ASSIGN                                                   !14, $90
  229   107        INIT_FCALL                                               'str_replace'
        108        SEND_VAL                                                 '%3Cspan%3ESelect%3A%3C%2Fspan%3E'
        109        SEND_VAL                                                 ''
        110        SEND_VAR                                                 !14
        111        DO_ICALL                                         $92     
        112        ASSIGN                                                   !14, $92
  230   113        CONCAT                                           ~94     !14, '%0A%3Cdiv+style%3D%22border-top%3A1px+solid+%23ccc%3B%22%3E%26nbsp%3B%3C%2Fdiv%3E%0A'
        114        ASSIGN                                                   !14, ~94
  233   115        INIT_FCALL_BY_NAME                                       'mysql_query'
        116        ROPE_INIT                                     3  ~97     'INSERT+INTO+aforms+%28html%29+VALUES+%28%27'
        117        ROPE_ADD                                      1  ~97     ~97, !14
        118        ROPE_END                                      2  ~96     ~97, '%27%29'
        119        SEND_VAL_EX                                              ~96
        120        DO_FCALL                                      0  $99     
        121      > JMPNZ_EX                                         ~100    $99, ->126
        122    >   INIT_FCALL_BY_NAME                                       'mysql_error'
        123        DO_FCALL                                      0  $101    
        124      > EXIT                                                     $101
        125*       BOOL                                             ~100    <true>
  234   126    >   INIT_FCALL_BY_NAME                                       'mysql_query'
        127        ROPE_INIT                                     3  ~103    'SELECT+%2A+FROM+aforms+WHERE+html%3D%27'
        128        ROPE_ADD                                      1  ~103    ~103, !14
        129        ROPE_END                                      2  ~102    ~103, '%27+ORDER+BY+id+DESC+LIMIT+1'
        130        SEND_VAL_EX                                              ~102
        131        DO_FCALL                                      0  $105    
        132        ASSIGN                                           ~106    !15, $105
        133      > JMPNZ_EX                                         ~106    ~106, ->138
        134    >   INIT_FCALL_BY_NAME                                       'mysql_error'
        135        DO_FCALL                                      0  $107    
        136      > EXIT                                                     $107
        137*       BOOL                                             ~106    <true>
  235   138    >   INIT_FCALL_BY_NAME                                       'mysql_fetch_array'
        139        SEND_VAR_EX                                              !15
        140        DO_FCALL                                      0  $108    
        141        ASSIGN                                                   !16, $108
  236   142        FETCH_DIM_R                                      ~110    !16, 'id'
        143        CONCAT                                           ~111    '%3Ca+href%3D%22http%3A%2F%2Fwww.mynoblecare.com%2Fview_form.php%3Fid%3D', ~110
        144        CONCAT                                           ~112    ~111, '%22%3EView+Form%3C%2Fa%3E'
        145        ASSIGN                                                   !17, ~112
  242   146        CONCAT                                           ~114    '%0A%3Chtml%3E%0A%3Chead%3E%0A%3Ctitle%3EAssessment+Form+Entry%3C%2Ftitle%3E%0A%3Cstyle%3E%0A', !4
        147        CONCAT                                           ~115    ~114, '%0A%3C%2Fstyle%3E%0A%3C%2Fhead%3E%0A%3Cbody%3E%0A'
        148        ASSIGN_OP                                     8          !18, ~115
  248   149        FETCH_R                      global              ~117    '_POST'
        150        FETCH_DIM_R                                      ~118    ~117, 'pt-name'
        151        CONCAT                                           ~119    '%0APatient+Name%3A+', ~118
        152        CONCAT                                           ~120    ~119, '%3Cbr%2F%3E%3Cbr%2F%3E%0A%0ASender+Email%3A+'
  250   153        CONCAT                                           ~121    ~120, !6
        154        CONCAT                                           ~122    ~121, '%3Cbr%2F%3E%3Cbr%2F%3E%0A%0ASender+Name%3A+'
  252   155        FETCH_R                      global              ~123    '_POST'
        156        FETCH_DIM_R                                      ~124    ~123, 'sender-fullname'
        157        CONCAT                                           ~125    ~122, ~124
        158        CONCAT                                           ~126    ~125, '%3Cbr%2F%3E%3Cbr%2F%3E%0A%0AScore%3A+'
  254   159        CONCAT                                           ~127    ~126, !11
        160        CONCAT                                           ~128    ~127, '+out+of+68%3Cbr%2F%3E%3Cbr%2F%3E%0A%0AScore+%28alternative+calculation%29%3A+'
  256   161        CONCAT                                           ~129    ~128, !12
        162        CONCAT                                           ~130    ~129, '+out+of+68%3Cbr%2F%3E%3Cbr%2F%3E%0A%0AOptional+Message%3A+'
  258   163        FETCH_R                      global              ~131    '_POST'
        164        FETCH_DIM_R                                      ~132    ~131, 'optional-msg'
        165        CONCAT                                           ~133    ~130, ~132
        166        CONCAT                                           ~134    ~133, '%3Cbr%2F%3E%3Cbr%2F%3E%0A'
  259   167        CONCAT                                           ~135    ~134, !17
        168        CONCAT                                           ~136    ~135, '%3B%0A%0A%24message+.%3D%22%3Cbr%2F%3E%3Cbr%2F%3E%0ARaw+Values%3A+'
  262   169        CONCAT                                           ~137    ~136, !10
        170        CONCAT                                           ~138    ~137, '%0A%3C%2Fbody%3E%0A%3C%2Fhtml%3E'
        171        ASSIGN_OP                                     8          !18, ~138
  265   172        INIT_FCALL                                               'mail'
        173        SEND_VAL                                                 'osamaejaz1%40gmail.com%2Cinfo%40mynoblecare.com'
        174        SEND_VAR                                                 !7
  266   175        SEND_VAR                                                 !18
        176        SEND_VAR                                                 !13
        177        DO_ICALL                                                 
  267   178        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'
        179      > JMP                                                      ->181
  269   180    >   ECHO                                                     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