@ 2013-09-30T18:35:45Z <?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 0.010 0.070 17.19 5.5.3 0.003 0.063 17.21 5.5.2 0.013 0.067 17.21 5.5.1 0.003 0.050 17.21 5.5.0 0.003 0.087 17.21 5.4.20 0.010 0.067 19.07 5.4.19 0.010 0.070 19.11 5.4.18 0.007 0.083 18.94 5.4.17 0.003 0.073 19.00 5.4.16 0.003 0.077 19.11 5.4.15 0.013 0.067 19.10 5.4.14 0.000 0.053 16.38 5.4.13 0.017 0.060 16.23 5.4.12 0.003 0.080 16.38 5.4.11 0.003 0.047 16.46 5.4.10 0.000 0.040 16.45 5.4.9 0.010 0.063 16.30 5.4.8 0.003 0.037 16.29 5.4.7 0.003 0.047 16.42 5.4.6 0.003 0.070 16.46 5.4.5 0.013 0.043 16.56 5.4.4 0.007 0.077 16.34 5.4.3 0.007 0.063 16.45 5.4.2 0.010 0.070 16.57 5.4.1 0.007 0.037 16.45 5.4.0 0.000 0.047 15.73 5.3.27 0.007 0.053 14.59 5.3.26 0.010 0.070 14.55 5.3.25 0.013 0.047 14.59 5.3.24 0.003 0.037 14.57 5.3.23 0.010 0.073 14.44 5.3.22 0.007 0.060 14.65 5.3.21 0.003 0.050 14.55 5.3.20 0.000 0.040 14.55 5.3.19 0.010 0.050 14.54 5.3.18 0.003 0.047 14.43 5.3.17 0.007 0.070 14.35 5.3.16 0.010 0.073 14.65 5.3.15 0.013 0.070 14.40 5.3.14 0.013 0.043 14.50 5.3.13 0.007 0.080 14.51 5.3.12 0.013 0.077 14.41 5.3.11 0.007 0.057 14.64 5.3.10 0.000 0.083 14.13 5.3.9 0.013 0.067 13.94 5.3.8 0.003 0.053 13.97 5.3.7 0.020 0.037 13.96 5.3.6 0.007 0.067 13.99 5.3.5 0.003 0.053 13.89 5.3.4 0.013 0.070 13.89 5.3.3 0.003 0.077 13.88 5.3.2 0.003 0.050 13.61 5.3.1 0.000 0.067 13.60 5.3.0 0.003 0.060 13.40
preferences:dark mode live preview
142.23 ms | 1394 KiB | 7 Q