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<?php
session_start();
require_once("../patientmanager.php");
require_once("../DBManager.php");
include('dashboarddocument.php');
include('header.php');
if(isset($_POST['sub']))
{
PatientManager::registerpatient("$_POST[familyid]","$_POST[familyid]","$_POST[typept]","$_POST[pic]","$_POST[fr]","$_POST[uname]","$_POST[patientname]","$_POST[gendor]","$_POST[HusbandName]","$_POST[Email]","$_POST[numbers]","$_POST[dob]","$_POST[Weight]","$_POST[Height]","$_POST[bloodgroup]","$_POST[Nationality]","$_POST[Marital]","$_POST[Religion]","$_POST[Occupation]","$_POST[Familyinc]","$_POST[Education]","$_POST[Passportnm]","$_POST[AadharNu]","$_POST[Referred]","$_POST[Country]","$_POST[State]","$_POST[city]","$_POST[Tahsil]","$_POST[locality]","$_POST[bloc]","$_POST[Street]","$_POST[pincode]","$_POST[nameofinc]","$_POST[Policynm]","$_POST[Dailyact]","$_POST[adNone]","$_POST[Alcohol]","$_POST[Smoking]","$_POST[Tobacco]","$_POST[fmNone]","$_POST[fmDiabetes]","$_POST[fmThyroid]","$_POST[fmHeart]","$_POST[fmHypertension]","$_POST[fmDepression]","$_POST[fmAnemia]","$_POST[fmThalassemia]","$_POST[fmHIV]","$_POST[None]","$_POST[Diabetes]","$_POST[Diabetesst]","$_POST[Thyroid]","$_POST[Thyroidst]","$_POST[PCOD]","$_POST[PCODst]","$_POST[Cholesterol]","$_POST[Cholesterolst]","$_POST[PhysicalInjury]","$_POST[PhysicalInjuryst]","$_POST[HeartCondition]","$_POST[HeartConditionst]","$_POST[Depression]","$_POST[Depressionst]","$_POST[Physicallychallenged]","$_POST[Physicallychallengedst]","$_POST[Mentallychallenged]","$_POST[Mentallychallengedst]","$_POST[TerminallyIll]","$_POST[TerminallyIllst]","$_POST[Dependency]","$_POST[Modn]","$_POST[Level]","$_POST[pin]","$_POST[entered_by]");
}
?>
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<title>PT | Basic</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<style>
table {
border-collapse: collapse;
border-spacing: 0;
width: 100%;
}
th, td {
text-align: left;
padding: 8px;
}
</style>
<script>
function myFunction() {
var checkBox = document.getElementById("myCheck");
var text = document.getElementById("text");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction1() {
var checkBox = document.getElementById("myCheck1");
var text = document.getElementById("text1");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction2() {
var checkBox = document.getElementById("myCheck2");
var text = document.getElementById("text2");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction3() {
var checkBox = document.getElementById("myCheck3");
var text = document.getElementById("text3");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction4() {
var checkBox = document.getElementById("myCheck4");
var text = document.getElementById("text4");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction5() {
var checkBox = document.getElementById("myCheck5");
var text = document.getElementById("text5");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction6() {
var checkBox = document.getElementById("myCheck6");
var text = document.getElementById("text6");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction7() {
var checkBox = document.getElementById("myCheck7");
var text = document.getElementById("text7");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction8() {
var checkBox = document.getElementById("myCheck8");
var text = document.getElementById("text8");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction9() {
var checkBox = document.getElementById("myCheck9");
var text = document.getElementById("text9");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction10() {
var checkBox = document.getElementById("myCheck10");
var text = document.getElementById("text10");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
</script>
<script>
var stateObject = {
"India": { "UttarPradesh": ["Agra","Aligarh","Allahabad","Ambedkar Nagar","Amethi (Chatrapati Sahuji Mahraj Nagar)", "Amroha (J.P. Nagar)","Auraiya", "Azamgarh", "Baghpat", "Bahraich", "Ballia", "Balrampur", "Banda", "Barabanki", "Bareilly", "Basti", "Bhadohi", "Bijnor", "Budaun", "Bulandshahr", "Chandauli", "Chitrakoot", "Deoria", "Etah", "Etawah", "Faizabad", "Farrukhabad", "Fatehpur", "Firozabad", "Gautam Buddha Nagar", "Ghaziabad", "Ghazipur", "Gonda", "Gorakhpur", "Hamirpur", "Hapur", "(Panchsheel Nagar) Hardoi", "Hathras","Jalaun", "Jaunpur", "Jhansi", "Kannauj", "Kanpur", "Dehat", "Kanpur Nagar", "Kanshiram Nagar(Kasganj)", "Kaushambi", "Kushinagar (Padrauna)", "Lakhimpur - Kheri", "Lalitpur","Lucknow","Maharajganj", "Mahoba", "Mainpuri", "Mathura", "Mau", "Meerut", "Mirzapur", "Moradabad", "Muzaffarnagar", "Pilibhit", "Prayagraj", "Pratapgarh", "RaeBareli", "Rampur","Saharanpur", "Sambhal (Bhim Nagar)", "Sant Kabir Nagar", "Shahjahanpur", "Shamali (Prabuddh Nagar)", "Shravasti", "Siddharth Nagar", "Sitapur", "Sonbhadra", "Sultanpur", "Unnao", "Varanasi"],
"Bihar": ["Araria", "Arwal", "Aurangabad", "Banka", "Begusarai", "Bhagalpur", "Bhojpur", "Buxar", "Darbhanga","Gaya","Gopalganj","Jamui", "Jehanabad","Kaimur (Bhabua)","Katihar", "Khagaria","Kishanganj","khisarai" ,"Madhepura","Madhubani","Munger","Muzaffarpur","Nalanda","Nawada", "Pashchim", "Champaran (West Champaran)","Patna","Purba", "Champaran (East Champaran)","Purnia","Rohtas","Saharsa","Samastipur","Saran","Sheikhpura", "Sheohar","Sitamarhi","Siwan","Supaul","Vaishali"],
"Uttarakhand": ["Almora","Bageshwar","Chamoli","Champawat","Dehradun", "Haridwar","Nainital", "Pauri","Pithoragarh", "Rudraprayag","Tehri","Udham Singh Nagar","Uttarkashi"],
},
"Australia": {
"South Australia": ["Dunstan", "Mitchell"],
"Victoria": ["Altona", "Euroa"]
}, "Canada": {
"Alberta": ["Acadia", "Bighorn"],
"Columbia": ["Washington", ""]
},
}
window.onload = function () {
var countySel = document.getElementById("countySel"),
stateSel = document.getElementById("stateSel"),
districtSel = document.getElementById("districtSel");
for (var country in stateObject) {
countySel.options[countySel.options.length] = new Option(country, country);
}
countySel.onchange = function () {
stateSel.length = 1; // remove all options bar first
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
for (var state in stateObject[this.value]) {
stateSel.options[stateSel.options.length] = new Option(state, state);
}
}
countySel.onchange(); // reset in case page is reloaded
stateSel.onchange = function () {
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
var district = stateObject[countySel.value][this.value];
for (var i = 0; i < district.length; i++) {
districtSel.options[districtSel.options.length] = new Option(district[i], district[i]);
}
}
}
</script>
<!-- MATERIAL DESIGN ICONIC FONT -->
</head>
<body>
<form name="sub" method="post">
<?php
$sqlpatient= "SELECT * FROM patient WHERE familyid='$_GET[familyid]'";
$qsqlpatient = mysqli_query($con,$sqlpatient);
while($rspatient=mysqli_fetch_array($qsqlpatient))
{
echo "<input type='hidden' name='familyid' id='familyid' value='$rspatient[familyid]'></td>";
}
?>
<?php
$sqlpatient= "SELECT * FROM admin WHERE adminid='$_GET[adminid]'";
$qsqlpatient = mysqli_query($con,$sqlpatient);
while($rspatient=mysqli_fetch_array($qsqlpatient))
{
echo "<input type='hidden' name='adminid' id='adminid' value='$rspatient[adminid]'></td>";
}
?> <div class="content-wrapper">
<!-- Content Header (Page header) -->
<section class="content-header">
<fieldset>
<legend>
<p>
<h3>Add New Patient</h3>
</legend>
<label> Name</label>
<input type="text" name="patientname" placeholder="Name" class="form-control">
<div class="checkbox"> <label> Gender</label></div>
<div class="checkbox"><input type="radio" name="gendor" value="Male"><span>Male </span></div><div class="checkbox"><input type="radio" name="gendor" value="female">
<span>female </span></div>
<label> Fathers/Husband Name</label>
<input type="text" name="HusbandName" placeholder="Fathers/Husband Name" class="form-control">
<label> Email</label>
<input type="email" name="Email" placeholder="Alternative Email" class="form-control">
<label> Contact Number </label>
<input type="text" name="mobileno" placeholder="Alternative Contact Number" class="form-control">
<label> DOB </label>
<input type="date" name="dob" class="form-control">
<label> Weight </label>
<input type="text" name="Weight" placeholder="Weight in Kilogram" class="form-control">
<label> Height </label>
<select name="Height" class="form-control">
<option value="0">Select Height</option>
<option value="4-6" > >4ft 6in / 137 cms</option>
<option value="4-6" >4ft 6in / 137 cms</option>
<option value="4-7" >4ft 7in / 139 cms</option>
<option value="4-8" >4ft 8in / 142 cms</option>
<option value="4-9" >4ft 9in / 144 cms</option>
<option value="4-10" >4ft 10in / 147 cms</option>
<option value="4-11" >4ft 11in / 149 cms</option>
<option value="5" >5ft / 152 cms</option>
<option value="5-1" >5ft 1in / 154 cms</option>
<option value="5-2" >5ft 2in / 157 cms</option>
<option value="5-3" >5ft 3in / 160 cms</option>
<option value="5-4" >5ft 4in / 162 cms</option>
<option value="5-5" >5ft 5in / 165 cms</option>
<option value="5-6" >5ft 6in / 167 cms</option>
<option value="5-7" >5ft 7in / 170 cms</option>
<option value="5-8" >5ft 8in / 172 cms</option>
<option value="5-9" >5ft 9in / 175 cms</option>
<option value="5-10" >5ft 10in / 177 cms</option>
<option value="5-11" >5ft 11in / 180 cms</option>
<option value="6" >6ft / 182 cms</option>
<option value="6-1" >6ft 1in / 185 cms</option>
<option value="6-2" >6ft 2in / 187 cms</option>
<option value="6-3" >6ft 3in / 190 cms</option>
<option value="6-4" >6ft 4in / 193 cms</option>
<option value="6-5" >6ft 5in / 195 cms</option>
<option value="6-6" >6ft 6in / 198 cms</option>
<option value="6-7" >6ft 7in / 200 cms</option>
<option value="6-8" >6ft 8in / 203 cms</option>
<option value="6-9" >6ft 9in / 205 cms</option>
<option value="6-10" >6ft 10in / 208 cms</option>
<option value="6-11" >6ft 11in / 210 cms</option>
<option value="7" >7ft / 213 cms</option>
</select>
<label> Blood Group </label>
<select name="bloodgroup" class="form-control">
<option value="">Blood Group</option>
<option value='A+'>A+</option><option value='A-'>A-</option><option value='B+'>B+</option><option value='B-'>B-</option><option value='O+'>O+</option><option value='O-'>O-</option><option value='AB+'>AB+</option><option value='AB-'>AB-</option>
</select>
<label> Nationality </label>
<select class="form-control" name="Nationality" id="COUNTRY"><option value="0">Nationality</option><option value="98" style="color:#004F00">India</option><option value="222" style="color:#004F00">United States of America</option><option value="220" style="color:#004F00">United Arab Emirates</option><option value="221" style="color:#004F00">United Kingdom</option><option value="13" style="color:#004F00">Australia</option><option value="189" style="color:#004F00">Singapore</option><option value="39" style="color:#004F00">Canada</option><option value="173" style="color:#004F00">Qatar</option><option value="114" style="color:#004F00">Kuwait</option><option value="161" style="color:#004F00">Oman</option><option value="17" style="color:#004F00">Bahrain</option><option value="185" style="color:#004F00">Saudi Arabia</option><option value="129" style="color:#004F00">Malaysia</option><option value="80" style="color:#004F00">Germany</option><option value="153" style="color:#004F00">New Zealand</option><option value="73" style="color:#004F00">France</option><option value="102" style="color:#004F00">Ireland</option><option value="203" style="color:#004F00">Switzerland</option><option value="193" style="color:#004F00">South Africa</option><option value="195" style="color:#004F00">Sri Lanka</option><option value="99" style="color:#004F00">Indonesia</option><option value="149" style="color:#004F00">Nepal</option><option value="162" style="color:#004F00">Pakistan</option><option value="18" style="color:#004F00">Bangladesh</option><option value="1" style="color:#004F00">Afghanistan</option></select>
<label> Marital status </label>
<select name="Marital" class="form-control">
<option value="" disabled selected>Marital status </option>
<option value="Single" label="single">Single</option>
<option value="Married" label="Married">Married</option>
<option value="Widowed">Widowed</option>
<option value="divorced" label="divorced">Divorced</option>
</select>
<label> Religion </label>
<select name="Religion" class="form-control">
<option value="" disabled selected>Religion </option>
<option value="Hindu" label="Hindu">Hindu</option>
<option value="Muslim" label="Muslim">Muslim</option>
<option value="Christian" label="Christian">Christian</option>
<option value="Sikh" label="Sikh">Sikh</option>
<option value="Parsi" label="Parsi">Parsi</option>
<option value="Jain" label="Jain">Jain</option>
<option value="Buddhist" label="Buddhist">Buddhist</option>
<option value="Jewish" label="Jewish">Jewish</option>
<option value="No Religion" label="No Religion">No Religion</option>
<option value="Spiritual - not religious" label="Spiritual">Spiritual</option>
<option value="Other" label="Other">Other</option>
</select>
<label> Occupation </label>
<select name="Occupation" class="form-control">
<option value="" disabled selected>Occupation </option>
<option value="Chief Executive and senior officers">Chief Executive and senior officers</option>
<option value="IT">IT</option>
<option value="Medical professionals">Medical professionals</option>
<option value="Services and sales">Services and sales</option>
<option value="Agricultural workers">Agricultural workers</option>
<option value="Agricultural workers">Homemaker</option>
<option value="Student">Student</option>
<option value="Other">Other</option>
</select>
<label> Family income </label>
<select name="Familyinc" class="form-control">
<option value="0">- Family Income -</option>
<option value="3">0 - 1 Lakh</option><option value="4">1 - 2 Lakhs</option><option value="5">2 - 3 Lakhs</option><option value="6">3 - 4 Lakhs</option><option value="7">4 - 5 Lakhs</option><option value="8">5 - 6 Lakhs</option><option value="9">6 - 7 Lakhs</option><option value="10">7 - 8 Lakhs</option><option value="11">8 - 9 Lakhs</option><option value="12">9 - 10 Lakhs</option><option value="13">10 - 12 Lakhs</option><option value="14">12 - 14 Lakhs</option><option value="15">14 - 16 Lakhs</option><option value="16">16 - 18 Lakhs</option><option value="17">18 - 20 Lakhs</option><option value="18">20 - 25 Lakhs</option><option value="19">25 - 30 Lakhs</option><option value="20">30 - 35 Lakhs</option><option value="21">35 - 40 Lakhs</option><option value="22">40 - 45 Lakhs</option><option value="23">45 - 50 Lakhs</option><option value="24">50 - 60 Lakhs</option><option value="25">60 - 70 Lakhs</option><option value="26">70 - 80 Lakhs</option><option value="27">80 - 90 Lakhs</option><option value="28">90 Lakhs - 1 Crore</option><option value="29">1 Crore & Above</option> </select>
<label> Education Qualification </label>
<select name="Education" class="form-control">
<option value="" disabled selected> Education Qualification</option>
<option value='Doctrate'>Doctorate</option>
<option value='Post Graduation'>Post Graduation</option>
<option value='Bachelor'>Graduation</option>
<option value='Diploma'>Diploma</option>
<option value='Higher Secondary School / High School'>Higher Secondary School / High School</option>
<option value='None Of Above'>None Of Above</option>
</select>
<label> Passport Number</label>
<input type="text" name="Passportnm" placeholder="Passport Number (In case of Foreign citizen)" class="form-control">
<label> Aadhar Number </label>
<input type="text" name="AadharNu" placeholder="Aadhar Number" class="form-control">
<label>Referred By </label>
<input type="text" name="Referred" placeholder="Referred By" class="form-control">
<!-- SECTION 5 -->
<label> Country </label><select name="Country" id="countySel" size="1" class="form-control">
<option value="" selected="selected">Select Country</option>
</select>
<label>State </label>
<select id="stateSel" size="1" class="form-control" name="State">
<option value="" selected="selected">Please select Country first</option>
</select>
<label> City </label>
<select id="districtSel" size="1" name="city" class="form-control">
<option value="" selected="selected">Please select State first</option>
</select>
<label>Pincode </label>
<input type="text" name="pincode" placeholder="Pincode" class="form-control">
<label> Address Line 1 </label>
<input type="text" name="bloc" placeholder="Address Line 1" class="form-control">
<label>Address Line 2 </label>
<input type="text" name="locality" placeholder="Address Line 2" class="form-control">
<label>Insurance Company Name </label>
<input type="text" name="nameofinc" placeholder="Name of Company" class="form-control">
<label>Policy Number </label>
<input type="text" name="Policynm" placeholder="Policy Number" class="form-control">
<label>Daily Activity </label>
<select name="Dailyact" id="cars" class="form-control">
<option value="" disabled selected>Daily Activity </option>
<option value="Sedentary (Little or No Exercise)">Sedentary
<br><br>(Little or No Exercise) </option>
<option value="Lightly Active (Light Exercise ">Lightly Active (Light Exercise /Sports 1-3 Days a week)</option>
<option value="Moderately Active (Moderate Exercise">Moderately Active (Moderate Exercise /Sports 3-5 days in a week)</option>
<option value="Moderately Active (Moderate Exercise">Very Active (Hard Exercise/Sports 6-7 days in a week) </option>
</select>
<div class="checkbox"> <input name="None" type="checkbox">
<span style="font-size:18px;"> None</h2></span></div>
<div class="checkbox"> <input id="myCheck" name="Diabetes" onclick="myFunction()" type="checkbox">
<span style="font-size:18px;">Diabetes</span></div>
<select id="text" name="Diabetesst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"><input id="myCheck1" name="Thyroid" onclick="myFunction1()" type="checkbox">
<span style="font-size:18px;">Thyroid</span></div>
<select id="text1" name="Thyroidst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox">
<input id="myCheck2" name="PCOD" onclick="myFunction2()" type="checkbox">
<span style="font-size:18px;"> PCOD</span></div>
<select name="PCODst" id="text2" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck3" name="Cholesterol" onclick="myFunction3()" type="checkbox">
<span style="font-size:18px;">Cholesterol</span></div>
<select name="Cholesterolst" id="text3" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"><input id="myCheck4" name="PhysicalInjury" onclick="myFunction4()" type="checkbox">
<span style="font-size:18px;">Physical Injury</span></div>
<select id="text4" name="PhysicalInjuryst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select> <div class="checkbox"> <input id="myCheck5" name="HeartCondition" onclick="myFunction5()" type="checkbox">
<span style="font-size:18px;">Heart Condition</span></div>
<select id="text5" name="HeartConditionst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck6" name="Hypertension" onclick="myFunction6()" type="checkbox">
<span style="font-size:18px;"> Hypertension</span></div>
<select name="Hypertensionst" id="text6" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck7" name="Depression" onclick="myFunction7()" type="checkbox">
<span style="font-size:18px;"> Depression</span></div>
<select id="text7" name="Depressionst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck8" name="Physicallychallenged" onclick="myFunction8()" type="checkbox">
<span style="font-size:18px;"> Physically challenged</span></div>
<select id="text8" name="Physicallychallengedst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck9" name="Mentallychallenged" onclick="myFunction9()" type="checkbox">
<span style="font-size:18px;"> Mentally challenged</span></div>
<select id="text9" name="Mentallychallengedst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
<div class="checkbox"> <input id="myCheck10" name="TerminallyIll" onclick="myFunction10()" type="checkbox">
<span style="font-size:18px;"> Terminally Ill </span></div>
<p id="text10" style="display:none" >
<input type="text" name="terSpecify" class="form-control" placeholder="Specify">
<select name="TerminallyIllst" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</p>
<br>
<label>Dependency</label>
<select name="Dependency" class="form-control">
<option value="" disabled selected>Dependency </option>
<option value="Independent">Independent</option>
<option value="Partially Dependent">Partially Dependent</option>
<option value="Completely Dependent">Completely Dependent </option>
</select>
<label>Mode of Movement </label>
<select name="Modn" class="form-control">
<option value="" disabled selected>Mode of Movement </option>
<option value="Independent">Ambulatory</option>
<option value="Wheel chair">Wheel chair</option>
<option value="Stretcher">Stretcher </option>
<option value="Physical Support">Physical Support </option>
</select>
<label>Level of Consciousness </label>
<select name="Level" class="form-control">
<option value="" disabled selected>Level of Consciousness </option>
<option value="Conscious">Conscious</option>
<option value="Semi Conscious">Semi Conscious</option>
<option value="Un-conscious ">Un-conscious </option>
</select>
<!-- SECTION 4 -->
<div style="overflow-x:auto;">
<table>
<th>Drug</th>
<th>Dose</th>
<th>Route</th>
<th>Frequency</th>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
</table>
</div>
<button type="submit" name="sub">Submit</button>
</div></form>
</body>
</html>