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<?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 &amp; 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'); ?>
Finding entry points
Branch analysis from position: 0
2 jumps found. (Code = 43) Position 1 = 9, Position 2 = 47
Branch analysis from position: 9
2 jumps found. (Code = 43) Position 1 = 16, Position 2 = 45
Branch analysis from position: 16
2 jumps found. (Code = 77) Position 1 = 22, Position 2 = 29
Branch analysis from position: 22
2 jumps found. (Code = 78) Position 1 = 23, Position 2 = 29
Branch analysis from position: 23
1 jumps found. (Code = 42) Position 1 = 22
Branch analysis from position: 22
Branch analysis from position: 29
1 jumps found. (Code = 42) Position 1 = 46
Branch analysis from position: 46
1 jumps found. (Code = 42) Position 1 = 50
Branch analysis from position: 50
1 jumps found. (Code = 62) Position 1 = -2
Branch analysis from position: 29
Branch analysis from position: 45
1 jumps found. (Code = 42) Position 1 = 50
Branch analysis from position: 50
Branch analysis from position: 47
1 jumps found. (Code = 62) Position 1 = -2
filename:       /in/sfeu0
function name:  (null)
number of ops:  53
compiled vars:  !0 = $pagetitle, !1 = $sitename, !2 = $active, !3 = $form, !4 = $styles, !5 = $email, !6 = $subject, !7 = $value, !8 = $name, !9 = $message1, !10 = $message
line      #* E I O op                           fetch          ext  return  operands
-------------------------------------------------------------------------------------
    2     0  E >   INCLUDE_OR_EVAL                                          'config.php', REQUIRE_ONCE
    5     1        CONCAT                                           ~12     'Forms+-+', !1
          2        ASSIGN                                                   !0, ~12
    8     3        ASSIGN                                                   !2, 'contact'
   15     4        FETCH_R                      global              ~15     '_GET'
          5        FETCH_DIM_R                                      ~16     ~15, 'form'
          6        ASSIGN                                                   !3, ~16
   16     7        IS_EQUAL                                                 !3, '1'
          8      > JMPZ                                                     ~18, ->47
   17     9    >   CONCAT                                           ~19     'Assessment+Form+-+', !1
         10        ASSIGN                                                   !0, ~19
   18    11        ASSIGN                                                   !4, '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'
   19    12        INCLUDE_OR_EVAL                                          'header.php', REQUIRE_ONCE
   21    13        ECHO                                                     '%3Ch1%3EAssessment+for+Admission%3C%2Fh1%3E%0A'
   22    14        FETCH_R                      global              ~23     '_POST'
         15      > JMPZ                                                     ~23, ->45
   24    16    >   FETCH_R                      global              ~24     '_REQUEST'
         17        FETCH_DIM_R                                      ~25     ~24, 'email'
         18        ASSIGN                                                   !5, ~25
   25    19        ASSIGN                                                   !6, 'Noble+Care+Assessment+Entry'
   26    20        FETCH_R                      global              ~28     '_POST'
         21      > FE_RESET_R                                       $29     ~28, ->29
         22    > > FE_FETCH_R                                       ~30     $29, !7, ->29
         23    >   ASSIGN                                                   !8, ~30
   27    24        CONCAT                                           ~32     !8, '%3A+'
         25        CONCAT                                           ~33     ~32, !7
         26        CONCAT                                           ~34     ~33, '+%7C+'
         27        ASSIGN                                                   !9, ~34
   26    28      > JMP                                                      ->22
         29    >   FE_FREE                                                  $29
   29    30        FETCH_R                      global              ~36     '_REQUEST'
         31        FETCH_DIM_R                                      ~37     ~36, 'email'
         32        CONCAT                                           ~38     'Email+is%3A+', ~37
         33        CONCAT                                           ~39     ~38, '%26%26%26+'
         34        CONCAT                                           ~40     ~39, !9
         35        ASSIGN                                                   !10, ~40
   30    36        INIT_FCALL                                               'mail'
         37        SEND_VAL                                                 'osamaejaz1%40gmail.com%2Cinfo%40mynoblecare.com'
         38        SEND_VAR                                                 !6
   31    39        SEND_VAR                                                 !10
         40        CONCAT                                           ~42     'From%3A', !5
         41        SEND_VAL                                                 ~42
         42        DO_ICALL                                                 
   32    43        ECHO                                                     '%3Ch2%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'
         44      > JMP                                                      ->46
   34    45    >   ECHO                                                     '%3Ch2%3EPlease+fill+out+the+following+form.%3C%2Fh2%3E%0A%3Cbr%2F%3E%0A%3Cform+style%3D%22overflow%3A+hidden%3Bpadding%3A+50px%3Bbackground%3A+rgba%28255%2C255%2C255%2C.4%29%3Bborder-radius%3A+20px%3B-moz-border-radius%3A+20px%3B-webkit-border-radius%3A+20px%3Bborder%3A+1px+solid+%23ccc%3B%22+method%3D%22POST%22+action%3D%22%22%3E%0A%3Cdiv+style%3D%22text-align%3A+center%3Bmargin-bottom%3A+20px%3Bmargin-left%3A+-120px%3B%22%3EPatient+Name%3A+%3Cbr%2F%3E%3Cinput+style%3D%22position%3A+relative%3Bleft%3A+80px%3B%22+type%3D%22text%22+class%3D%22input%22+placeholder%3D%22Patient%27s+name%22+%2F%3E%3Cbr%2F%3E%3Cbr%2F%3E%3C%2Fdiv%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22veryweak%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22good%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22veryweak%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%22friendly%22%3EFriendly%3C%2Foption%3E%0A%3Coption+value%3D%22indifferent%22%3EIndifferent%3C%2Foption%3E%0A%3Coption+value%3D%22agitated%22%3EAgitated%3C%2Foption%3E%0A%3Coption+value%3D%22aggressive%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22restricted%22%3ERestricted%3C%2Foption%3E%0A%3Coption+value%3D%22with-support%22%3EMove+with+Support%3C%2Foption%3E%0A%3Coption+value%3D%22total-bed-ridden%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22poor%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%22least-understand%22%3ELeast+Understand%3C%2Foption%3E%0A%3Coption+value%3D%22cannot-speak%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22good%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%22poor%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%22verypoor%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22poor%22%3EPoor%3C%2Foption%3E%0A%3Coption+value%3D%22weak%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22veryweak%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22veryweak%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22veryweak%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%22good%22%3EGood%3C%2Foption%3E%0A%3Coption+value%3D%22minor-ill%22%3EMinor+ill%3C%2Foption%3E%0A%3Coption+value%3D%22major-illness%22%3EMajor+illness%3C%2Foption%3E%0A%3Coption+value%3D%22terminal%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%22nil%22%3ENil%3C%2Foption%3E%0A%3Coption+value%3D%22small%22%3ESmall%3C%2Foption%3E%0A%3Coption+value%3D%22large%22%3ELarge%3C%2Foption%3E%0A%3Coption+value%3D%22many%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22assisted%22%3EAssisted%3C%2Foption%3E%0A%3Coption+value%3D%22no-self-feeding%22%3ENo+Self-Feed%3C%2Foption%3E%0A%3Coption+value%3D%22ng-tube%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22frequent%22%3EFrequent%3C%2Foption%3E%0A%3Coption+value%3D%22uncontrolled%22%3EUncontrolled%3C%2Foption%3E%0A%3Coption+value%3D%22catheter%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22frequent%22%3EFrequent%3C%2Foption%3E%0A%3Coption+value%3D%22uncontrolled%22%3EUncontrolled%3C%2Foption%3E%0A%3Coption+value%3D%22pampered%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%22nil%22%3ENil%3C%2Foption%3E%0A%3Coption+value%3D%22oldfolks-home%22%3EOld+Folks+Home%3C%2Foption%3E%0A%3Coption+value%3D%22nursing-home%22%3ENursing++Home%3C%2Foption%3E%0A%3Coption+value%3D%22hospital%22%3EHospital%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cdiv+class%3D%22sfield%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%22normal%22%3ENormal%3C%2Foption%3E%0A%3Coption+value%3D%22fair%22%3EFair%3C%2Foption%3E%0A%3Coption+value%3D%22weak%22%3EWeak%3C%2Foption%3E%0A%3Coption+value%3D%22nil%22%3ENil%3C%2Foption%3E%0A%3C%2Fselect%3E%0A%3C%2Fdiv%3E%0A%3Cinput+type%3D%22submit%22+value%3D%22Submit%22+style%3D%22margin-left%3A+160px%3Bwidth%3A200px%3B%22+class%3D%22btn-submit%22+%2F%3E%0A%3C%2Fform%3E%0A%0A%0A%0A%0A'
         46    > > JMP                                                      ->50
  216    47    >   INIT_FCALL                                               'header'
         48        SEND_VAL                                                 'Location%3A+%2Fnot-found'
         49        DO_ICALL                                                 
  223    50    >   INCLUDE_OR_EVAL                                          'sidebar.php', REQUIRE_ONCE
  224    51        INCLUDE_OR_EVAL                                          'footer.php', REQUIRE_ONCE
  225    52      > RETURN                                                   1

Generated using Vulcan Logic Dumper, using php 8.0.0


preferences:
159.01 ms | 1408 KiB | 17 Q