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<?php
include("header.php");
include("menu.php");
if(isset($_POST[submit]))
{
if(isset($_GET[editid]))
{
$sql ="UPDATE prescription SET treatment_records_id='$_POST[treatmentid]',doctorid='$_POST[select2]',patientid='$_POST[patientid]',prescriptiondate='$_POST[date]',status='$_POST[select]' WHERE prescription_id='$_GET[editid]'";
if($qsql = mysqli_query($con,$sql))
{
echo "<script>alert('prescription record updated successfully...');</script>";
}
else
{
echo mysqli_error($con);
}
}
else
{
$sql ="INSERT INTO pgmedication(doctorid,patientid,patientname,gender,Age,Address,mobileno,doctorname,AdmissionDate,DischargeDate) values('$_POST[select2]','$_POST[patientid]','$_POST[patientname]','$_POST[gender]','$_POST[Age]','$_POST[Address]','$_POST[mobileno]','$_POST[doctorname]','$_POST[AdmissionDate]','$_POST[DischargeDate]')";
if($qsql = mysqli_query($con,$sql))
{
$insid= mysqli_insert_id($con);
$prescriptionid= $insid;
$prescriptiondate= $_POST[date];
$billtype="Prescription charge";
$billamt=0;
include("insertbillingrecord.php");
echo "<script>alert(' record inserted successfully...');</script>";
echo "<script>window.location='Diagnosis.php?prescriptionid=" . $insid . "&patientid=$_GET[patientid]&appid=$_GET[appid]';</script>";
}
else
{
echo mysqli_error($con);
}
}
}
if(isset($_GET[editid]))
{
$sql="SELECT * FROM prescription WHERE prescriptionid='$_GET[editid]' ";
$qsql = mysqli_query($con,$sql);
$rsedit = mysqli_fetch_array($qsql);
}
?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Medication</title>
<style>
table{
width: 100%;
margin: 20px 0;
border-collapse: collapse;
}
table, th, td{
border: 1px solid #cdcdcd;
}
table th, table td{
padding: 5px;
text-align: left;
}
</style>
<script>
$('input[type="checkbox"]').change(function(e) {
var checked = $(this).prop("checked"),
container = $(this).parent(),
siblings = container.siblings();
container.find('input[type="checkbox"]').prop({
indeterminate: false,
checked: checked
});
function checkSiblings(el) {
var parent = el.parent().parent(),
all = true;
el.siblings().each(function() {
let returnValue = all = ($(this).children('input[type="checkbox"]').prop("checked") === checked);
return returnValue;
});
if (all && checked) {
parent.children('input[type="checkbox"]').prop({
indeterminate: false,
checked: checked
});
checkSiblings(parent);
} else if (all && !checked) {
parent.children('input[type="checkbox"]').prop("checked", checked);
parent.children('input[type="checkbox"]').prop("indeterminate", (parent.find('input[type="checkbox"]:checked').length > 0));
checkSiblings(parent);
} else {
el.parents("li").children('input[type="checkbox"]').prop({
indeterminate: true,
checked: false
});
}
}
checkSiblings(container);
});
</script>
<style>
body {
padding: 20px;
}
ul {
list-style: none;
margin: 5px 20px;
}
li {
margin: 10px 0;
}
</style>
<script src="https://code.jquery.com/jquery-1.12.4.min.js"></script>
<script>
$(document).ready(function(){
$(".add-row").click(function(){
var Drug = $("#Drug").val();
var Dose = $("#Dose").val();
var Route = $("#Route").val();
var Frequency = $("#Frequency").val();
var markup = "<tr><td><input type='checkbox' name='record'></td><td>" + Drug + "</td><td>" + Dose + "</td><td>" + Route + "</td><td>" + Frequency + "</td></tr>";
$("table tbody").append(markup);
});
// Find and remove selected table rows
$(".delete-row").click(function(){
$("table tbody").find('input[name="record"]').each(function(){
if($(this).is(":checked")){
$(this).parents("tr").remove();
}
});
});
});
</script>
<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 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";
}
}
function myFunction11() {
var checkBox = document.getElementById("myCheck11");
var text = document.getElementById("text11");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction12() {
var checkBox = document.getElementById("myCheck12");
var text = document.getElementById("text12");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction13() {
var checkBox = document.getElementById("myCheck13");
var text = document.getElementById("text13");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction14() {
var checkBox = document.getElementById("myCheck14");
var text = document.getElementById("text14");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction15() {
var checkBox = document.getElementById("myCheck15");
var text = document.getElementById("text15");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction16() {
var checkBox = document.getElementById("myCheck16");
var text = document.getElementById("text16");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction17() {
var checkBox = document.getElementById("myCheck17");
var text = document.getElementById("text17");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction18() {
var checkBox = document.getElementById("myCheck18");
var text = document.getElementById("text18");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction19() {
var checkBox = document.getElementById("myCheck19");
var text = document.getElementById("text19");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction20() {
var checkBox = document.getElementById("myCheck20");
var text = document.getElementById("text20");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction21() {
var checkBox = document.getElementById("myCheck21");
var text = document.getElementById("text21");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction22() {
var checkBox = document.getElementById("myCheck22");
var text = document.getElementById("text22");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction23() {
var checkBox = document.getElementById("myCheck23");
var text = document.getElementById("text23");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction24() {
var checkBox = document.getElementById("myCheck24");
var text = document.getElementById("text24");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction25() {
var checkBox = document.getElementById("myCheck25");
var text = document.getElementById("text25");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction26() {
var checkBox = document.getElementById("myCheck26");
var text = document.getElementById("text26");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction27() {
var checkBox = document.getElementById("myCheck27");
var text = document.getElementById("text27");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction28() {
var checkBox = document.getElementById("myCheck28");
var text = document.getElementById("text28");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
</script>
</head>
<body>
<form>
<div class="content-wrapper">
<!-- Content Header (Page header) -->
<section class="content-header">
<ul>
<li><div class="w3-half">
<input type="checkbox" name="Emergency" >
<label for="Emergency">None </label>
</div>
<div class="w3-half">
<input type="checkbox" name="Diabetes" id="myCheck" onclick="myFunction()">
<label for="Emergency">Diabetes </label>
</div>
<p id="text" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck2" onclick="myFunction2()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck3" onclick="myFunction3()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text2" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text3" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Thyroid" id="myCheck4" onclick="myFunction4()">
<label for="Emergency">Thyroid </label>
</div>
<p id="text4" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck5" onclick="myFunction5()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck6" onclick="myFunction6()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text5" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text6" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="PCOD" id="myCheck7" onclick="myFunction7()">
<label for="Emergency">PCOD </label>
</div>
<p id="text7" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck8" onclick="myFunction8()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck9" onclick="myFunction9()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text8" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text9" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Cholesterol" id="myCheck10" onclick="myFunction10()">
<label for="Emergency">Cholesterol </label>
</div>
<p id="text10" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck11" onclick="myFunction11()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck12" onclick="myFunction12()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text11" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text12" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Physical Injury" id="myCheck13" onclick="myFunction13()">
<label for="Emergency">Physical Injury </label>
</div>
<p id="text13" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck14" onclick="myFunction14()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck15" onclick="myFunction15()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text14" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text15" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Hypertension" id="myCheck16" onclick="myFunction16()">
<label for="Emergency">Hypertension </label>
</div>
<p id="text16" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck17" onclick="myFunction17()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck18" onclick="myFunction18()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text17" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text18" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Hypertension" id="myCheck19" onclick="myFunction19()">
<label for="Emergency">Physically challenged </label>
</div>
<p id="text19" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck20" onclick="myFunction20()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck21" onclick="myFunction21()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text20" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text21" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Hypertension" id="myCheck22" onclick="myFunction22()">
<label for="Emergency">Mentally challenged </label>
</div>
<p id="text22" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck23" onclick="myFunction23()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck24" onclick="myFunction24()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text23" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text24" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
<ul>
<li>
<div class="w3-half">
<input type="checkbox" name="Terminally ill" id="myCheck25" onclick="myFunction25()">
<label for="Emergency">Terminally ill </label>
</div>
<p id="text25" style="display:none">
<input type="checkbox" name="Cured">
<label for="Physiotherapy">Cured </label>
<input type="checkbox" id="myCheck26" onclick="myFunction26()" name="Confirmed">
<label for="Confirmed">Confirmed </label>
<input type="checkbox" id="myCheck27" onclick="myFunction27()" name="Active" >
<label for=" Active "> Active </label>
</p>
<p id="text26" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</p>
<p id="text27" style="display:none">
<input type="text" onfocus=this.value='' name="Drug" id="textBox" placeholder="Drug">
<input type="text" onfocus=this.value='' name="Dose" id="textBox" placeholder="Dose">
<select name="Route">
<option value="" disabled selected>Route Type </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>
<select name="Frequency">
<option value="" disabled selected>Drug 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>
<input type="button" class="add-row" value="Add Row">
<button type="button" class="delete-row">Delete Row</button>
<tr>
</ul>
</p>
</p>
</form>
<table>
<tbody>
</tbody>
</table>
<input onClick="redirect()" type="submit" name="submit" id="submit" value="Save & Next" />
</body>
</html>