Your IP : 216.73.216.91

Current Path : /var/www/html/llcfapp/public/
Upload File :
Current File : /var/www/html/llcfapp/public/health_print.php

<?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" class="print_form">
        <input type="hidden" name="id" id="id" value="<?=(isset($_GET['id']) && !empty($_GET['id'])) ? $_GET['id'] : "-1";?>">
        <input type="hidden" name="student_id" id="student_id" value="-1">
        <input type="hidden" name="family_id" id="family_id" value="-1">
            <fieldset>
                <h2 class="form-heading">LLCF Student Health Card</h2>
                <hr class="colorgraph">
                <div class="row form-group">
                    <div class="col-lg-2 col-md-2  col-sm-12">
                        <label>GR #</label>
                        <input value="<?php if(isset($_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-3  col-sm-12">
                        <label>Temprature(&#8457;)</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-3  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-2 col-md-2  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-2 col-md-2  col-sm-12">
                        <label>&nbsp;</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>Anemic</label>
                        <select disabled name="anemic" id="anemic" class="form-control input-lg" >
                            <option value="">No</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 disabled name="lice" id="lice" class="form-control input-lg" >
                            <option value="">No</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 disabled name="consciousness" id="consciousness" class="form-control input-lg" >
                            <option value="">No</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 disabled name="diet" id="diet" class="form-control input-lg" >
                            <option value="">No</option>
                            <option value="Mild">Good</option>
                            <option value="Moderate">Normal</option>
                            <option value="Severe">Bad</option>
                        </select>
                    </div>
                    <div class="col-lg-2 col-md-2  col-sm-12">
                        <label>Teeth Problem</label>
                        <select disabled name="teeth" id="teeth" class="form-control input-lg" >
                            <option value="">No</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-6 col-md-6  col-sm-12">
                        <label>History</label>
                        <textarea disabled name="history" id="history" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                    <div class="col-lg-6 col-md-6  col-sm-12">
                        <label>Diagnosis</label>
                        <textarea disabled name="diagnosis" id="diagnosis" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                </div>
                <div class="row form-group">
                    <div class="col-lg-6 col-md-6  col-sm-12">
                        <label>Management</label>
                        <textarea disabled name="management" id="management" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                    <div class="col-lg-6 col-md-6  col-sm-12">
                        <label>Advice</label>
                        <textarea disabled 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-6 col-md-6  col-sm-12">
                        <label>Refer</label>
                        <textarea disabled name="refer" id="refer" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                    <div class="col-lg-6 col-md-6  col-sm-12">
                        <label>Follow up</label>
                        <textarea disabled name="followup" id="followup" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                </div>
                <div class="row form-group">
                    <div class="col-lg-12 col-md-12  col-sm-12">
                        <label>Session</label>
                        <textarea disabled name="session" id="session" class="form-control input-lg" placeholder="Please type here"></textarea>
                    </div>
                </div>
                <hr class="colorgraph thin">
            </fieldset>
        </form>
    </div>
</div>