Online PHP editor | rfc for sfeu0

<?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'); ?>

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