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<?php
session_start();
include("dbconnection.php");
require_once("../LoginManager.php");
require_once("../DBManager.php");
require_once("../patientmanager.php");
include('menu.php');
include('header.php');
if(isset($_POST['sub']))
{
PatientManager::registerpatient("$_POST[familyid]","$_POST[headnumber]","$_POST[pic]","$_POST[fr]","$_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]","$_POST[pincode]","$_POST[bloc]","$_POST[nameofinc]","$_POST[Policynm]","$_POST[entered_by]");
}
?>
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<title>PT | Basic</title>
<link rel="stylesheet" href="https://www.w3schools.com/w3css/4/w3.css">
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.4.1/jquery.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/selectize.js/0.12.6/js/standalone/selectize.min.js" integrity="sha256-+C0A5Ilqmu4QcSPxrlGpaZxJ04VjsRjKu+G82kl5UJk=" crossorigin="anonymous"></script>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/selectize.js/0.12.6/css/selectize.bootstrap3.min.css" integrity="sha256-ze/OEYGcFbPRmvCnrSeKbRTtjG4vGLHXgOqsyLFTRjg=" crossorigin="anonymous" />
<link rel="stylesheet" href="select2.min.css" />
<style>
.select2-dropdown {top: 22px !important; left: 8px !important;}
</style>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>
<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;
}
select {
width: 25%;
}
option {
width: 25%;
}
</style>
<link rel="stylesheet" href="select2.min.css" />
<style>
.select2-dropdown {top: 22px !important; left: 8px !important;}
</style>
</head>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>
<script>
function isNumber(evt) {
evt = (evt) ? evt : window.event;
var charCode = (evt.which) ? evt.which : evt.keyCode;
if (charCode > 31 && (charCode < 48 || charCode > 57)) {
alert("Please enter only Numbers.");
return false;
}
return true;
}
function ValidateNo() {
var phoneNo = document.getElementById('numbers');
if (phoneNo.value == "" || phoneNo.value == null) {
alert("Please enter your Mobile No.");
return false;
}
if (phoneNo.value.length < 10 || phoneNo.value.length > 10) {
alert("Mobile No. is not valid, Please Enter 10 Digit Mobile No.");
return false;
}
return true;
}
$(function() {
$('#expradio').click(function() {
$('.txbx').attr('hidden',false);
});
$('#frsradio').click(function() {
$('.txbx').attr('hidden',true);
});
});
$(function() {
$('#frsradioage').click(function() {
$('.txbxage').attr('hidden',false);
});
$('#expradio').click(function() {
$('.txbxage').attr('hidden',true);
});
});
</script>
<script type="text/javascript">
$(document).ready(function() {
$('input[type="radio"]').click(function() {
var inputValue = $(this).attr("value");
var targetBox = $("." + inputValue);
$(".selectt").not(targetBox).hide();
$(targetBox).show();
});
});
</script>
<!-- MATERIAL DESIGN ICONIC FONT -->
</head>
<body>
<form name="sub" method="post">
<div class="content-wrapper">
<!-- Content Header (Page header) -->
<section class="content-header">
<p>
<h3>Add New Patient</h3>
<?php
include("dbconnection.php");
require_once('../DBManager.php');
require_once('../LoginManager.php');
$narayan=LoginManager::currentUser();
$usertype=LoginManager::getUserTypeByuname("$narayan");
$sql1 ="SELECT * FROM site_users WHERE userno='$usertype'";
$qsql1 = mysqli_query($con,$sql1);
if($re = mysqli_fetch_array($qsql1))
{
echo"<input type='hidden' name='familyid' value='$re[entered_by]'>
";
}
?>
<label> Contact Number <span style="color:red">*</span></label>
<input type="text" onchange="mobile(this.value)" name="numbers" placeholder="Contact Number" id="numbers" onkeypress="return isNumber(event)" required>
<div id='divmb'></div>
<label> Name <span style="color:red">*</span></label>
<input onclick="ValidateNo();" type="text" name="patientname" style="text-transform: capitalize;" placeholder="Name" required>
<div class="checkbox"> <label> <b>Gender</b> <span style="color:red">*</span></label></div>
<div class="checkbox"><input onclick="ValidateNo();" type="radio" name="gendor" value="Male" required><span>Male </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="gendor" value="female" >
<span>female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="gendor" value="Other" >
<span>Other </span></div>
<label> Fathers/Husband Name <span style="color:red">*</span></label>
<input onclick="ValidateNo();" type="text" name="HusbandName" placeholder="Fathers/Husband Name" style="text-transform: capitalize;" required>
<label> Email </label>
<input onclick="ValidateNo();" type="email" name="Email" placeholder="Email" class="form-control">
<br><label> Age<span style="color:red">*</span> </label><div class="checkbox"><input type='number' name='dob' id='select'><select id='select'>
<option>Years</option>
<option>Month</option>
<option>Days</option>
</select> </div>
<label> Weight </label>
<input onclick="ValidateNo();" type="text" name="Weight" placeholder="Weight in Kilogram" class="form-control">
<label> Height </label>
<select onclick="ValidateNo();" name="Height" class="form-control">
<option value="0">Select Height</option>
<option value="39">1ft 3in / 39 cms </option>
<option value="41">1ft 4in / 41 cms </option>
<option value="45">1ft 6in / 45 cms </option>
<option value="47">1ft 7in / 47 cms </option>
<option value="51">1ft 8in / 51 cms </option>
<option value="55">1ft 9in / 55 cms </option>
<option value="57">1ft 10in / 57 cms </option>
<option value="59">1ft 11in / 59 cms </option>
<option value="61">2ft 61 cms </option>
<option value="65">2ft 1in / 65 cms </option>
<option value="67">2ft 2in / 67 cms </option>
<option value="69">2ft 3in / 69 cms </option>
<option value="73">2ft 4in / 73 cms </option>
<option value="75">2ft 5in / 75 cms </option>
<option value="77">2ft 6in / 77 cms </option>
<option value="79">2ft 7in / 79 cms </option>
<option value="83">2ft 8in / 83 cms </option>
<option value="85">2ft 9in / 85 cms </option>
<option value="87">2ft 10in / 87 cms </option>
<option value="89">2ft 11in / 89 cms </option>
<option value="93">3ft 93 cms </option>
<option value="95">3ft 1in / 95 cms </option>
<option value="97">3ft 2in / 97 cms </option>
<option value="101">3ft 31in / 101 cms </option>
<option value="103">3ft 4in / 103 cms </option>
<option value="105">3ft 5in / 105 cms </option>
<option value="107">3ft 6in / 107 cms </option>
<option value="111">3ft 7in / 111 cms </option>
<option value="113">3ft 8in / 113 cms </option>
<option value="115">3ft 9in / 115 cms </option>
<option value="117">3ft 10in / 117 cms </option>
<option value="121">3ft 11in / 121 cms </option>
<option value="123">4ft 123 cms </option>
<option value="125">4ft 1in / 125 cms </option>
<option value="127">4ft 2in / 127 cms </option>
<option value="131">4ft 3in / 131 cms </option>
<option value="133">4ft 4in / 133 cms </option>
<option value="135">4ft 5in / 135 cms </option>
<option value="137" > >3ft 10in / 137 cms</option>
<option value="139" >4ft 7in / 139 cms</option>
<option value="142" >4ft 8in / 142 cms</option>
<option value="144" >4ft 9in / 144 cms</option>
<option value="147" >4ft 10in / 147 cms</option>
<option value="149" >4ft 11in / 149 cms</option>
<option value="152" >5ft / 152 cms</option>
<option value="154" >5ft 1in / 154 cms</option>
<option value="157" >5ft 2in / 157 cms</option>
<option value="160" >5ft 3in / 160 cms</option>
<option value="162" >5ft 4in / 162 cms</option>
<option value="165" >5ft 5in / 165 cms</option>
<option value="167" >5ft 6in / 167 cms</option>
<option value="170" >5ft 7in / 170 cms</option>
<option value="172" >5ft 8in / 172 cms</option>
<option value="175" >5ft 9in / 175 cms</option>
<option value="177" >5ft 10in / 177 cms</option>
<option value="180" >5ft 11in / 180 cms</option>
<option value="182" >6ft / 182 cms</option>
<option value="185" >6ft 1in / 185 cms</option>
<option value="187" >6ft 2in / 187 cms</option>
<option value="190" >6ft 3in / 190 cms</option>
<option value="193" >6ft 4in / 193 cms</option>
<option value="195" >6ft 5in / 195 cms</option>
<option value="198" >6ft 6in / 198 cms</option>
<option value="200" >6ft 7in / 200 cms</option>
<option value="203" >6ft 8in / 203 cms</option>
<option value="205" >6ft 9in / 205 cms</option>
<option value="208" >6ft 10in / 208 cms</option>
<option value="210" >6ft 11in / 210 cms</option>
<option value="213" >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 name="Nationality" class="form-control"><option value="0">Nationality</option><option value="Indian" style="color:#004F00">Indian</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="Business Owner">Business Owner</option>
<option value="Director ,Chief Executive & Senior officers">Director ,Chief Executive & Senior officers</option>
<option value="I.T Professionals">I.T Professionals </option>
<option value="Medical professionals">Medical professionals</option>
<option value="Bank Professional
">Bank Professional
</option>
<option value="Services and sales">Services and sales</option>
<option value="Agricultural workers">Agricultural workers</option>
<option value="Defense Services">Defense Services</option>
<option value="Homemakers">Homemakers</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="1 - 2 Lakhs">1 - 2 Lakhs</option><option value="2 - 3 Lakhs">2 - 3 Lakhs</option><option value="3 - 4 Lakhs">3 - 4 Lakhs</option><option value="4 - 5 Lakhs">4 - 5 Lakhs</option><option value="5 - 6 Lakhs">5 - 6 Lakhs</option><option value="6 - 7 Lakhs">6 - 7 Lakhs</option><option value="7 - 8 Lakhs">7 - 8 Lakhs</option><option value="8 - 9 Lakhs">8 - 9 Lakhs</option><option value="9 - 10 Lakhs">9 - 10 Lakhs</option><option value="10 - 12 Lakhs">10 - 12 Lakhs</option><option value="12 - 14 Lakhs">12 - 14 Lakhs</option><option value="14 - 16 Lakhs">14 - 16 Lakhs</option><option value="16 - 18 Lakhs">16 - 18 Lakhs</option><option value="18 - 20 Lakhs">18 - 20 Lakhs</option><option value="20 - 25 Lakhs">20 - 25 Lakhs</option><option value="19">25 - 30 Lakhs</option><option value="25 - 30 Lakhs">30 - 35 Lakhs</option><option value="35 - 40 Lakhs">35 - 40 Lakhs</option><option value="40 - 45 Lakhs">40 - 45 Lakhs</option><option value="45 - 50 Lakhs">45 - 50 Lakhs</option><option value="50 - 60 Lakhs">50 - 60 Lakhs</option><option value="60 - 70 Lakhs">60 - 70 Lakhs</option><option value="70 - 80 Lakhs">70 - 80 Lakhs</option><option value="80 - 90 Lakhs">80 - 90 Lakhs</option><option value="90 Lakhs - 1 Crore">90 Lakhs - 1 Crore</option><option value="1 Crore & Above">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='Graduation'>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)" >
<label> Aadhar Number </label>
<input type="text" name="AadharNu" placeholder="Aadhar Number" class="form-control" >
<!-- SECTION 5 -->
<label>Country <span style="color:red">*</span></label>
<select name="Country" class="form-control" required>
<option value="" disabled selected>Country</option>
<option value="India">India</option>
</select>
<label>State Name <span style="color:red">*</span></label><select name="State" class="form-control" onchange="stateload(this.value)" required>
<option value="" disabled selected>State Name</option>
<option value="Uttar Pradesh">Uttar Pradesh</option>
<option value="Bihar">Bihar </option>
<option value="Madhya Pradesh">Madhya Pradesh</option>
<option value="Kerala">Kerala</option>
<option value="West Bengal">West Bengal</option>
<option value="Andhra Pradesh">Andhra Pradesh</option>
<option value="Gujarat">Gujarat</option>
<option value="Meghalaya">Meghalaya</option>
<option value="Uttarakhand">Uttarakhand</option>
<option value="Punjab">Punjab</option>
<option value="Tamil Nadu">Tamil Nadu</option>
<option value="Maharashtra">Maharashtra</option>
<option value="Odisha">Odisha</option>
<option value="Jammu and Kashmir">Jammu and Kashmir</option>
<option value="Nagaland">Nagaland</option>
<option value="Puducherry">Puducherry</option>
<option value="Assam">Assam</option>
<option value="Karnataka">Karnataka</option>
<option value="Chandigarh">Chandigarh</option>
<option value="Manipur">Manipur</option>
<option value="Andaman and Nicobar">Andaman and Nicobar</option>
<option value="Lakshadweep">Lakshadweep</option>
<option value="Delhi">Delhi</option>
<option value="Telangana">Telangana</option>
<option value="Tripura">Tripura</option>
<option value="Haryana">Haryana</option>
<option value="Himachal Pradesh">Himachal Pradesh</option>
<option value="Jharkhand">Jharkhand</option>
<option value="Dadra and Nagar Haveli">Dadra and Nagar Haveli</option>
<option value="Ladakh">Ladakh</option>
<option value="Sikkim">Sikkim</option>
<option value="Arunachal Pradesh">Arunachal Pradesh</option>
</select>
<label>Districts Name <span style="color:red">*</span></label>
<div id='divds'>
<select name="city" class="form-control" required>
<option value="" disabled selected>Districts Name</option>
<option value="Agra"> Agra</option>
<option value="Aligarh">Aligarh</option>
<option value="Allahabad">Allahabad</option>
<option value="Ambedkar Nagar">Ambedkar Nagar</option>
<option value="Amethi">Amethi (Chatrapati Sahuji Mahraj Nagar)</option>
<option value="Amroha (J.P. Nagar)">Amroha (J.P. Nagar)</option>
<option value="Auraiya">Auraiya</option>
<option value="Azamgarh">Azamgarh</option>
<option value="Baghpat">Baghpat</option>
<option value="Bahraich">Bahraich</option>
<option value="Balrampur">Ballia</option>
<option value="Balrampur">Balrampur</option>
<option value="Banda">Banda</option>
<option value="Barabanki">Barabanki</option>
<option value="Bareilly">Bareilly</option>
<option value="Basti">Basti</option>
<option value="Bhadohi">Bhadohi</option>
<option value="Bijnor">Bijnor</option>
<option value="Budaun">Budaun</option>
<option value="Bulandshahr">Bulandshahr</option>
<option value="Chandauli">Chandauli</option>
<option value="Chitrakoot">Chitrakoot</option>
<option value="Deoria">Deoria</option>
<option value="Etah">Etah</option>
<option value="Etawah">Etawah</option>
<option value="Faizabad">Faizabad</option>
<option value="Farrukhabad">Farrukhabad</option>
<option value="Fatehpur">Fatehpur</option>
<option value="Firozabad">Firozabad</option>
<option value="Gautam Buddha Nagar">Gautam Buddha Nagar</option>
<option value="Ghaziabad">Ghaziabad</option>
<option value="Ghazipur">Ghazipur</option>
<option value="Gonda">Gonda</option>
<option value="Gorakhpur">Gorakhpur</option>
<option value="Hamirpur">Hamirpur</option>
<option value="Hapur (Panchsheel Nagar)">Hapur (Panchsheel Nagar)</option>
<option value="Hardoi">Hardoi</option>
<option value="Hathras">Hathras</option>
<option value="Jalaun">Jalaun</option>
<option value="Jaunpur">Jaunpur</option>
<option value="Jhansi">Jhansi</option>
<option value="Kannauj">Kannauj</option>
<option value="Kanpur Dehat">Kanpur Dehat</option>
<option value="Kanpur Nagar">Kanpur Nagar</option>
<option value="Kanshiram Nagar (Kasganj)">Kanshiram Nagar (Kasganj)</option>
<option value="Kushinagar (Padrauna)">Kushinagar (Padrauna)</option>
<option value="Lakhimpur - Kheri">Lakhimpur - Kheri</option>
<option value="Lalitpur">Lalitpur</option>
<option value="Lucknow">Lucknow</option>
<option value="Maharajganj">Maharajganj</option>
<option value="Mahoba">Mahoba</option>
<option value="Mainpuri">Mainpuri</option>
<option value="Mathura">Mathura</option>
<option value="Mau">Mau</option>
<option value="Meerut">Meerut</option>
<option value="Mirzapur">Mirzapur</option>
<option value="Moradabad">Moradabad</option>
<option value="Muzaffarnagar">Muzaffarnagar</option>
<option value="Pilibhit">Pilibhit</option>
<option value="RaeBareli">Pratapgarh</option>
<option value="RaeBareli">RaeBareli</option>
<option value="Rampur">Rampur</option>
<option value="Saharanpur">Saharanpur</option>
<option value="Sambhal (Bhim Nagar)">Sambhal (Bhim Nagar)</option>
<option value="Sant Kabir Nagar">Sant Kabir Nagar</option>
<option value="Shahjahanpur">Shahjahanpur</option>
<option value="Shamali (Prabuddh Nagar)">Shamali (Prabuddh Nagar)</option>
<option value="Shravasti">Shravasti</option>
<option value="Siddharth Nagar">Siddharth Nagar</option>
<option value="Sitapur">Sitapur</option>
<option value="Sonbhadra">Sonbhadra</option>
<option value="Sultanpur">Sultanpur</option>
<option value="Unnao">Unnao</option>
<option value="Varanasi">Varanasi</option>
</select>
</div>
<label>Pincode </label>
<input type="text" name="pincode" placeholder="Pincode" class="form-control" >
<label> Address </label>
<input type="text" name="bloc" placeholder="Address Line 1" class="form-control" >
<label>Insurance Company Name </label>
<select name="nameofinc" class="form-control">
<option value="">Insurance Company Name </option>
<?php
include("dbconnection.php");
$sqlpatient1 = "SELECT * FROM tpa_insurance";
$qsqlpatient1 = mysqli_query($con,$sqlpatient1);
while($rsn = mysqli_fetch_array($qsqlpatient1))
{
echo "<option value='$rsn[id]'>$rsn[Name]</option>";
}
?>
</td>
</select>
<label>Policy Number </label>
<input type="text" name="Policynm" placeholder="Policy Number" class="form-control">
<button type="submit" name="sub">Submit</button>
</form>
<script>
function mobile(mbid)
{
if (window.XMLHttpRequest) {
// code for IE7+, Firefox, Chrome, Opera, Safari
xmlhttp = new XMLHttpRequest();
} else {
// code for IE6, IE5
xmlhttp = new ActiveXObject("Microsoft.XMLHTTP");
}
xmlhttp.onreadystatechange = function() {
if (this.readyState == 4 && this.status == 200) {
document.getElementById("divmb").innerHTML = this.responseText;
}
};
xmlhttp.open("GET","loadmobile.php?mbid="+mbid,true);
xmlhttp.send();
}
</script>
<script>
function stateload(stid)
{
if (window.XMLHttpRequest) {
// code for IE7+, Firefox, Chrome, Opera, Safari
xmlhttp = new XMLHttpRequest();
} else {
// code for IE6, IE5
xmlhttp = new ActiveXObject("Microsoft.XMLHTTP");
}
xmlhttp.onreadystatechange = function() {
if (this.readyState == 4 && this.status == 200) {
document.getElementById("divds").innerHTML = this.responseText;
}
};
xmlhttp.open("GET","loadstate.php?stid="+stid,true);
xmlhttp.send();
}
</script>
<script>
$(document).ready(function () {
$('select12').selectize({
sortField: 'text'
});
});
</script>