<?php
require_once('config.php');
//Page Title
$pagetitle='Forms - '.$sitename;
//active menu item
$active="contact";
/*
$description=' Whatever you want';
$metakeywords'keyword1,2,2 etc';
*/
$form=$_GET['form'];
if($form=='1'){
$pagetitle='Assessment Form - '.$sitename;
$styles='select { width:100px; float:right;} .btn-submit {background:#ccc;} .sfield { margin-bottom:10px; border-bottom:1px solid #ddd;overflow: hidden;padding: 10px;}';
require_once('header.php');
?>
<h1>Assessment for Admission</h1>
<?php if($_POST){
//send email
$email = $_REQUEST['email'] ;
$subject = 'Noble Care Assessment Entry' ;
foreach($_POST as $name => $value) {
$message1 = $name.': '.$value.' | ';
}
$message = 'Email is: '.$_REQUEST['email'].'&&& '.$message1;
mail("osamaejaz1@gmail.com,info@mynoblecare.com", $subject,
$message, "From:" . $email);
echo '<h2>Thank You!</h2><p style="margin-left:20px;">Your Assessment form is sent. You will be replied soon.</p>';
} else { ?>
<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-bottom: 20px;margin-left: -120px;">Patient Name: <br/><input style="position: relative;left: 80px;" type="text" class="input" placeholder="Patient's name" /><br/><br/></div>
<div class="sfield">
General Health Status:
<select name="general-health-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Physical Fitness:
<select name="physical-fitness">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="good">Good</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">Social behavior:
<select name="social-behavior">
<option>Select:</option>
<option value="friendly">Friendly</option>
<option value="indifferent">Indifferent</option>
<option value="agitated">Agitated</option>
<option value="aggressive">Aggressive</option>
</select>
</div>
<div class="sfield">Mobility & Body Movements:
<select name="movement">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="restricted">Restricted</option>
<option value="with-support">Move with Support</option>
<option value="total-bed-ridden">Total Bed Ridden</option>
</select>
</div>
<div class="sfield">
Speech & Communication:
<select name="speech-and-communication">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="poor">Poor</option>
<option value="least-understand">Least Understand</option>
<option value="cannot-speak">Cannot Speak</option>
</select>
</div>
<div class="sfield">
Interpersonal Relations:
<select name="interpersonal-relations">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="good">Good</option>
<option value="poor">Poor</option>
<option value="verypoor">Very Poor</option>
</select>
</div>
<div class="sfield">
Level of Understanding:
<select name="understanding">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="poor">Poor</option>
<option value="weak">Weak</option>
</select>
</div>
<div class="sfield">
Learning Ability and Memory:
<select name="learning-and-memory">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Vision (Eye Sight):
<select name="vision-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Hearing Level:
<select name="hearing-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="veryweak">Very Weak</option>
</select>
</div>
<div class="sfield">
Health Condition:
<select name="health-condition">
<option>Select:</option>
<option value="good">Good</option>
<option value="minor-ill">Minor ill</option>
<option value="major-illness">Major illness</option>
<option value="terminal">Terminal</option>
</select>
</div>
<div class="sfield">
Wounds, Bed Sores etc:
<select name="wounds-status">
<option>Select:</option>
<option value="nil">Nil</option>
<option value="small">Small</option>
<option value="large">Large</option>
<option value="many">Many</option>
</select>
</div>
<div class="sfield">
Feeding and Drinking:
<select name="feeding-drinking-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="assisted">Assisted</option>
<option value="no-self-feeding">No Self-Feed</option>
<option value="ng-tube">N G TUBE</option>
</select>
</div>
<div class="sfield">
Urine:
<select name="urine-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="frequent">Frequent</option>
<option value="uncontrolled">Uncontrolled</option>
<option value="catheter">Catheter</option>
</select>
</div>
<div class="sfield">
Motion/Stool/Bowel:
<select name="motion-status">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="frequent">Frequent</option>
<option value="uncontrolled">Uncontrolled</option>
<option value="pampered">Pampered</option>
</select>
</div>
<div class="sfield">
Previous Admissions:
<select name="previous-admission-status">
<option>Select:</option>
<option value="nil">Nil</option>
<option value="oldfolks-home">Old Folks Home</option>
<option value="nursing-home">Nursing Home</option>
<option value="hospital">Hospital</option>
</select>
</div>
<div class="sfield">
General Self Care:
<select name="general-self-care">
<option>Select:</option>
<option value="normal">Normal</option>
<option value="fair">Fair</option>
<option value="weak">Weak</option>
<option value="nil">Nil</option>
</select>
</div>
<input type="submit" value="Submit" style="margin-left: 160px;width:200px;" class="btn-submit" />
</form>
<?php
}
} else {
header("Location: /not-found");
}
?>
<?php
require_once('sidebar.php');
require_once('footer.php');
?>
preferences:
35.3 ms | 402 KiB | 5 Q