Your IP : 216.73.216.91
<?php require_once('header.php');?>
<div class="container container-margin">
<div class="mx-auto col-12 col-md-12 col-lg-12">
<form method="post" id="create_health_card_form">
<input type="hidden" name="id" id="id" value="<?=(isset($_GET['id']) && !empty($_GET['id'])) ? $_GET['id'] : "-1";?>">
<input type="hidden" name="student_id" id="student_id" value="-1">
<input type="hidden" name="family_id" id="family_id" value="-1">
<fieldset>
<h2 class="form-heading">Health Card</h2>
<hr class="colorgraph">
<div class="row form-group">
<div class="col-lg-2 col-md-2 col-sm-12">
<label>GR #</label>
<input value="<?php if(isset($_GET['gr_num']) && !empty($_GET['gr_num'])){echo $_GET['gr_num'];}?>" type="text" name="gr_num" id="gr_num" class="form-control input-lg" placeholder="Enter GR #">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Automated GR #</label>
<input value="" type="text" name="auto_gr_num" id="auto_gr_num" class="form-control input-lg" disabled placeholder="Enter Automated GR #">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Student Full Name</label>
<input type="text" name="stu_full_name" id="stu_full_name" class="form-control input-lg alert-success valid" disabled>
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Father Name</label>
<input type="text" name="father_name" id="father_name" class="form-control input-lg" disabled>
</div>
</div>
<div class="row form-group">
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Student DOB</label>
<input type="date" name="stu_dob" id="stu_dob" class="form-control input-lg" disabled>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Age</label>
<input type="text" name="stu_age" id="stu_age" class="form-control input-lg" disabled>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Gender</label>
<input type="text" name="stu_gender" id="stu_gender" class="form-control input-lg" disabled>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Check Up Date</label>
<input type="date" name="checkup_date" id="checkup_date" class="form-control input-lg" value="">
</div>
</div>
<div class="row form-group">
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Heart / Pulse(Per Min)</label>
<input value="" type="text" name="pulse" id="pulse" class="form-control input-lg" placeholder="Enter heart rate">
</div>
<div class="col-lg-3 col-md-2 col-sm-12">
<label>Temprature(℉)</label>
<input type="text" name="body_temp" id="body_temp" class="form-control input-lg" placeholder="Enter temprature">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Respiration(Per Min)</label>
<input type="text" name="respiration" id="respiration" class="form-control input-lg" placeholder="Enter breathing Rate">
</div>
<div class="col-lg-3 col-md-2 col-sm-12">
<label>BP(mmHg)</label>
<input type="text" name="bp" id="bp" class="form-control input-lg" placeholder="Enter BP: Up/Down">
</div>
</div>
<div class="row form-group">
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Height(cm)</label>
<input type="text" name="height_cm" id="height_cm" class="form-control input-lg" placeholder="cm">
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Weight(kg)</label>
<input type="text" name="weight" id="weight" class="form-control input-lg" placeholder="Weight in kgs">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>BMI</label>
<input readonly type="text" name="bmi" id="bmi" class="form-control input-lg" placeholder="BMI">
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>BMI Percentile</label>
<input readonly type="text" name="bmi_percentile" id="bmi_percentile" class="form-control input-lg" placeholder="BMI Percentile">
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Eye Checkup</label>
<input type="text" name="eye_left" id="eye_left" class="form-control input-lg" placeholder="Left">
</div>
<div class="col-lg-1 col-md-1 col-sm-12">
<label> </label>
<input type="text" name="eye_right" id="eye_right" class="form-control input-lg" placeholder="Right">
</div>
</div>
<div class="row form-group">
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Appearance / Anemia</label>
<select name="pallor" id="pallor" class="form-control input-lg" >
<option value="None">None</option>
<option value="Mild">Mild</option>
<option value="Moderate">Moderate</option>
<option value="Severe">Severe</option>
</select>
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Lice</label>
<select name="lice" id="lice" class="form-control input-lg" >
<option value="None">None</option>
<option value="Mild">Mild</option>
<option value="Moderate">Moderate</option>
<option value="Severe">Severe</option>
</select>
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Consciousness / Mental Health</label>
<select name="consciousness" id="consciousness" class="form-control input-lg" >
<option value="None">None</option>
<option value="Mild">Mild</option>
<option value="Moderate">Moderate</option>
<option value="Good">Good</option>
</select>
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Diet Habbit</label>
<select name="diet" id="diet" class="form-control input-lg" >
<option value="">Select</option>
<option value="Healthy">Healthy</option>
<option value="Unhealthy">Unhealthy</option>
</select>
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Teeth Problem</label>
<select name="teeth" id="teeth" class="form-control input-lg" >
<option value="None">None</option>
<option value="Mild">Mild</option>
<option value="Moderate">Moderate</option>
<option value="Severe">Severe</option>
</select>
</div>
</div>
<div class="row form-group">
<div class="col-lg-3 col-md-3 col-sm-12">
<label>History</label>
<textarea name="history" id="history" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Diagnosis</label>
<textarea name="diagnosis" id="diagnosis" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Management</label>
<textarea name="management" id="management" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Advice</label>
<textarea name="advice" id="advice" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
</div>
<div class="row form-group">
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Refer</label>
<textarea name="refer" id="refer" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Follow up</label>
<textarea name="followup" id="followup" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Session</label>
<textarea name="session" id="session" class="form-control input-lg" placeholder="Please type here"></textarea>
</div>
</div>
<hr class="colorgraph thin">
<div class="row form-group">
<div class="col-lg-4 col-md-4 col-sm-12">
<input type="submit" id="health_submit" class="btn btn-lg btn-primary btn-block llcf-pri" value="Save">
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<input type="button" id="reset" class="btn btn-lg btn-danger btn-block" value="Reset">
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<a class="btn btn-lg btn-secondary btn-block" href="<?=Config::getConfig('healthGridRedirect')?>">Checkup List</a>
</div>
</div>
</fieldset>
</form>
</div>
</div>
<?php require_once('footer.php');?>