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<?php
session_start();
require_once("../../../patientmanager.php");
require_once("../../../DBManager.php");
if(!isset($_SESSION['uname']))
{
echo "<script>alert('Session Expired..');</script><script>window.location='../index.php';</script>";
}
$title='Add Referral';
$narayan=LoginManager::currentUser();
$harilal=LoginManager::getUserTypeByuname("$narayan");
$sql ="SELECT * FROM site_users WHERE userno='$harilal'";
$qsql = mysqli_query($con,$sql);
$rs = mysqli_fetch_array($qsql);
if(isset($_POST['signup']))
{
PatientManager::patientreferral("$_GET[prescriptionid]","$_GET[patientid]","$_POST[hs_referral]","$_POST[location]","$_POST[Phone]","$_POST[Email]","$_POST[Accompanied]","$_POST[Primary_Diagnosis]","$_POST[Treatments_initiated]","$_POST[Types_Patient]","$_POST[Transportation_needs]","$_POST[Follow_up_requirements]","$_POST[Mobility]","$_POST[Self_care]","$_POST[Cognitive_impairment]","$_POST[Assistive_devices_provide]","$_POST[Assistive_required]","$_POST[Nurse_Name]","$_POST[entered_by]");
}
?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1" />
<meta charset="utf-8" />
<title><?php echo $title; ?></title>
<meta name="description" content="Common form elements and layouts" />
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0" />
<!-- bootstrap & fontawesome -->
<link rel="stylesheet" href="../assets/css/bootstrap.min.css" />
<link rel="stylesheet" href="../assets/font-awesome/4.5.0/css/font-awesome.min.css" />
<!-- page specific plugin styles -->
<link rel="stylesheet" href="../assets/css/jquery-ui.custom.min.css" />
<link rel="stylesheet" href="../assets/css/chosen.min.css" />
<link rel="stylesheet" href="../assets/css/bootstrap-datepicker3.min.css" />
<link rel="stylesheet" href="../assets/css/bootstrap-timepicker.min.css" />
<link rel="stylesheet" href="../assets/css/daterangepicker.min.css" />
<link rel="stylesheet" href="../assets/css/bootstrap-datetimepicker.min.css" />
<link rel="stylesheet" href="../assets/css/bootstrap-colorpicker.min.css" />
<!-- text fonts -->
<link rel="stylesheet" href="../assets/css/fonts.googleapis.com.css" />
<!-- ace styles -->
<link rel="stylesheet" href="../assets/css/ace.min.css" class="ace-main-stylesheet" id="main-ace-style" />
<!--[if lte IE 9]>
<link rel="stylesheet" href="../assets/css/ace-part2.min.css" class="ace-main-stylesheet" />
<![endif]-->
<link rel="stylesheet" href="../assets/css/ace-skins.min.css" />
<link rel="stylesheet" href="../assets/css/ace-rtl.min.css" />
<!--[if lte IE 9]>
<link rel="stylesheet" href="../assets/css/ace-ie.min.css" />
<![endif]-->
<!-- inline styles related to this page -->
<!-- ace settings handler -->
<script src="../assets/js/ace-extra.min.js"></script>
<!-- HTML5shiv and Respond.js for IE8 to support HTML5 elements and media queries -->
<!--[if lte IE 8]>
<script src="../assets/js/html5shiv.min.js"></script>
<script src="../assets/js/respond.min.js"></script>
<![endif]-->
</head>
<body class="no-skin">
<?php include('../includes/header.php'); ?>
<div class="main-container ace-save-state" id="main-container">
<script type="text/javascript">
try{ace.settings.loadState('main-container')}catch(e){}
</script>
<div id="sidebar" class="sidebar responsive ace-save-state">
<script type="text/javascript">
try{ace.settings.loadState('sidebar')}catch(e){}
</script>
<div class="sidebar-shortcuts" id="sidebar-shortcuts">
<div class="sidebar-shortcuts-large" id="sidebar-shortcuts-large">
<button class="btn btn-success">
<i class="ace-icon fa fa-signal"></i>
</button>
<button class="btn btn-info">
<i class="ace-icon fa fa-pencil"></i>
</button>
<button class="btn btn-warning">
<i class="ace-icon fa fa-users"></i>
</button>
<button class="btn btn-danger">
<i class="ace-icon fa fa-cogs"></i>
</button>
</div>
<div class="sidebar-shortcuts-mini" id="sidebar-shortcuts-mini">
<span class="btn btn-success"></span>
<span class="btn btn-info"></span>
<span class="btn btn-warning"></span>
<span class="btn btn-danger"></span>
</div>
</div><!-- /.sidebar-shortcuts -->
<?php include('sidebar.php'); ?><!-- /.nav-list -->
<div class="sidebar-toggle sidebar-collapse" id="sidebar-collapse">
<i id="sidebar-toggle-icon" class="ace-icon fa fa-angle-double-left ace-save-state" data-icon1="ace-icon fa fa-angle-double-left" data-icon2="ace-icon fa fa-angle-double-right"></i>
</div>
</div>
<div class="main-content">
<div class="main-content-inner">
<div class="breadcrumbs ace-save-state" id="breadcrumbs">
<ul class="breadcrumb">
<li>
<i class="ace-icon fa fa-home home-icon"></i>
<a href="#">Home</a>
</li>
<li class="active"><?php echo $title; ?></li>
</ul><!-- /.breadcrumb -->
<div class="nav-search" id="nav-search">
<form class="form-search">
<span class="input-icon">
<input type="text" placeholder="Search ..." class="nav-search-input" id="nav-search-input" autocomplete="off" />
<i class="ace-icon fa fa-search nav-search-icon"></i>
</span>
</form>
</div><!-- /.nav-search -->
</div>
<div class="page-content">
<div class="ace-settings-container" id="ace-settings-container">
<div class="btn btn-app btn-xs btn-warning ace-settings-btn" id="ace-settings-btn">
<i class="ace-icon fa fa-cog bigger-130"></i>
</div>
<div class="ace-settings-box clearfix" id="ace-settings-box">
<div class="pull-left width-50">
<div class="ace-settings-item">
<div class="pull-left">
<select id="skin-colorpicker" class="hide">
<option data-skin="no-skin" value="#438EB9">#438EB9</option>
<option data-skin="skin-1" value="#222A2D">#222A2D</option>
<option data-skin="skin-2" value="#C6487E">#C6487E</option>
<option data-skin="skin-3" value="#D0D0D0">#D0D0D0</option>
</select>
</div>
<span> Choose Skin</span>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-navbar" autocomplete="off" />
<label class="lbl" for="ace-settings-navbar"> Fixed Navbar</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-sidebar" autocomplete="off" />
<label class="lbl" for="ace-settings-sidebar"> Fixed Sidebar</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-breadcrumbs" autocomplete="off" />
<label class="lbl" for="ace-settings-breadcrumbs"> Fixed Breadcrumbs</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-rtl" autocomplete="off" />
<label class="lbl" for="ace-settings-rtl"> Right To Left (rtl)</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-add-container" autocomplete="off" />
<label class="lbl" for="ace-settings-add-container">
Inside
<b>.container</b>
</label>
</div>
</div><!-- /.pull-left -->
<div class="pull-left width-50">
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-hover" autocomplete="off" />
<label class="lbl" for="ace-settings-hover"> Submenu on Hover</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-compact" autocomplete="off" />
<label class="lbl" for="ace-settings-compact"> Compact Sidebar</label>
</div>
<div class="ace-settings-item">
<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-highlight" autocomplete="off" />
<label class="lbl" for="ace-settings-highlight"> Alt. Active Item</label>
</div>
</div><!-- /.pull-left -->
</div><!-- /.ace-settings-box -->
</div><!-- /.ace-settings-container -->
<div class="page-header">
<h1>
<small>
<i class="ace-icon fa fa-angle-double-right"></i>
<?php echo $title; ?>
</small>
</h1>
</div><!-- /.page-header -->
<div class="row">
<div class="col-xs-12">
<div class="panel panel-primary">
<div class="panel-body">
<h4 class="text-on-pannel text-primary"><strong class="text-uppercase">Referral </strong></h4>
<!-- PAGE CONTENT BEGINS -->
<form name="signup" method="post">
<table id='example2' class='table table-bordered table-hover' width='100%'>
<tr>
<td width='50%'> Referral to: </td>
<td width='50%'>
<input onkeyup="this.value = this.value.toUpperCase();" placeholder='Name of facility or service' onchange="Referralload(this.value)" name='hs_referral' type='text' list='hs_referral' class='form-control'>
<datalist name='hs_referral' id='hs_referral'>
<?php
include("dbconnection.php");
$sqlpatient1 = "SELECT * FROM admin";
$qsqlpatient1 = mysqli_query($con,$sqlpatient1);
while($rsn = mysqli_fetch_array($qsqlpatient1))
{
echo "
<option value=''>Name of facility or service</option>
<option value='$rsn[hsname]'>$rsn[hsname]</option>";
}
?>
</td>
</datalist></td>
</tr>
</table>
<div id='divdr'>
<table id='example2' class='table table-bordered table-hover' width='100%'>
<tr>
<td width='50%'> Location: </td>
<td width='50%'><input type='text' name='location' placeholder='Location' class='form-control' />
</td>
</tr>
<tr>
<td width='50%'> Phone: </td>
<td width='50%'>
<input type='text' name='Phone' placeholder='Phone' class='form-control' />
</td>
</tr>
<tr>
<td width='50%'> Email: </td>
<td width='50%'>
<input type='text' name='Email' placeholder='Email' class='form-control' />
</td>
</tr>
</table>
</div>
<table id='example2' class='table table-bordered table-hover' width='100%'>
<?php
$narayan=LoginManager::currentUser();
$usertype=LoginManager::getUserTypeByuname("$narayan");
$sql ="SELECT * FROM site_users WHERE userno='$usertype'";
$qsql = mysqli_query($con,$sql);
if($rs = mysqli_fetch_array($qsql))
{
$sql ="SELECT * FROM hco WHERE adminid='$rs[entered_by]'";
$qsql = mysqli_query($con,$sql);
if($rs = mysqli_fetch_array($qsql))
{
$sql ="SELECT * FROM admin WHERE id='$rs[adminid]'";
$qsql = mysqli_query($con,$sql);
if($ra = mysqli_fetch_array($qsql))
{
echo"<tr>
<td width='50%'> Referring from: </td>
<td width='50%'> $ra[hsname]</td></tr>
<tr>
<td width='50%'> Location: </td>
<td width='50%'> $rs[Street] | $rs[Locality]</td></tr>
<tr>
<td width='50%'> Phone: </td>
<td width='50%'> $ra[numbers]</td></tr>
<tr>
<td width='50%'> Email Id: </td>
<td width='50%'> $ra[EmailID]</td></tr>
";
}
}
}
?>
</table>
<table id='example2' class='table table-bordered table-hover' width='100%'><tr>
<th>Patient Information</th></tr>
</table>
<table id='example2' class='table table-bordered table-hover' width='100%'>
<?php
$sql ="SELECT * FROM patient WHERE patientid='$_GET[patientid]'";
$qsql = mysqli_query($con,$sql);
while($rs = mysqli_fetch_array($qsql))
{
echo "
<tr>
<td width='50%'> Full Name : </td>
<td width='50%'>$rs[patientname]</td>
</tr>
<tr>
<td width='50%'> Phone : </td>
<td width='50%'>$rs[numbers]</td>
</tr>
<tr>
<td width='50%'> DOB: </td>
<td width='50%'>$rs[dob]</td>
</tr>
<tr>
<td width='50%'> Sex : </td>
<td width='50%'>$rs[gendor]</td>
</tr>
";
echo "</td></tr>"; }
?>
<tr>
<td width='50%'> Accompanied by care provider : </td>
<td width='50%'><label class='switch'>
<input name='Accompanied' type='checkbox' class="ace ace-switch ace-switch-6">
<span class='lbl'></span>
</label>
</td>
</tr>
<tr>
<td width='50%'> Primary Diagnosis : </td>
<td width='50%'><textarea name="Primary_Diagnosis" rows="3" cols="50" class='form-control'/>
</textarea>
</td>
</tr>
<tr>
<td width='50%'> Treatments initiated : </td>
<td width='50%'><textarea name="Treatments_initiated" rows="3" cols="50" class='form-control'/>
</textarea>
</td>
</tr>
<tr>
<td width='50%'> Types of Patient : </td>
<td width='50%'><select name='Types_Patient' class='form-control'>
<option value='Admission Consent' disabled selected>Types of Patient</option>
<option value='Inpatient'>Inpatient</option>
<option value='Outpatient'>Outpatient </option>
<option value='Community'>Community</option>
</select></td>
</tr>
<tr>
<td width='50%'> Transportation needs : </td>
<td width='50%'><select name='Transportation_needs' class='form-control'>
<option value='Admission Consent' disabled selected>Transportation needs</option>
<option value='Yes'>Yes</option>
<option value='No'>No </option>
</select></td>
</tr>
<tr>
<td width='50%'> Follow_up_requirements : </td>
<td width='50%'><input type='text' name='Follow_up_requirements' Placeholder='Follow-up requirements' class='form-control'>
</td>
</tr>
</table>
<table id='example2' class='table table-bordered table-hover' width='100%'><tr>
<th>Functional Status</th></tr>
</table>
<table id='example2' class='table table-bordered table-hover' width='100%'>
<tr>
<td width='50%'> Mobility : </td>
<td width='50%'><select name='Mobility' class='form-control'>
<option disabled selected>Mobility</option>
<option value='Bed bound'>Bed bound</option>
<option value='Wheelchair'>Wheelchair</option>
<option value='Crutches'>Crutches</option>
<option value='Walking frame'>Walking frame</option>
<option value='Requires assistance'>Requires assistance</option>
<option value='Independent'>Independent</option>
</select></td>
</tr>
<tr>
<td width='50%'> Self-care : </td>
<td width='50%'><select name='Self_care' class='form-control'>
<option disabled selected>Self-care</option>
<option value='Carer dependent'>Carer dependent</option>
<option value='Requires commode'>Requires commode</option>
<option value='Requires modified latrine/washroom'>Requires modified latrine/washroom</option>
<option value='Independent'>Independent</option>
</select></td>
</tr>
<tr>
<td width='50%'> Cognitive impairment : </td>
<td width='50%'><label class='switch'>
<input name='Cognitive_impairment' type='checkbox' class="ace ace-switch ace-switch-6">
<span class='lbl'></span>
</label>
</td>
</tr>
<tr>
<td width='50%'> Assistive devices(s) provided : </td>
<td width='50%'><textarea name="Assistive_devices_provide" rows="2" cols="50" class='form-control'>
</textarea>
</td>
</tr>
<tr>
<td width='50%'> Assistive device(s) required:
</td>
<td width='50%'><textarea name="Assistive_required" rows="2" cols="50" class='form-control'>
</textarea>
</td>
</tr>
</table>
</td><td></td><input type="hidden" name='Nurse_Name' placeholder='Created By' class='form-control'>
<br><br>
<input type="submit" name="signup" value="Submit" class='btn btn-success'>
</form>
</div></div>
</div><!-- /.col -->
</div><!-- /.row -->
</div><!-- /.page-content -->
</div>
</div><!-- /.main-content -->
<?php include('includes/footer.php'); ?>
<a href="#" id="btn-scroll-up" class="btn-scroll-up btn btn-sm btn-inverse">
<i class="ace-icon fa fa-angle-double-up icon-only bigger-110"></i>
</a>
</div><!-- /.main-container -->
<!-- basic scripts -->
<!--[if !IE]> -->
<script src="../assets/js/jquery-2.1.4.min.js"></script>
<!-- <![endif]-->
<!--[if IE]>
<script src="../assets/js/jquery-1.11.3.min.js"></script>
<![endif]-->
<script type="text/javascript">
if('ontouchstart' in document.documentElement) document.write("<script src='../assets/js/jquery.mobile.custom.min.js'>"+"<"+"/script>");
</script>
<script src="../assets/js/bootstrap.min.js"></script>
<!-- page specific plugin scripts -->
<!--[if lte IE 8]>
<script src="../assets/js/excanvas.min.js"></script>
<![endif]-->
<script src="../assets/js/jquery-ui.custom.min.js"></script>
<script src="../assets/js/jquery.ui.touch-punch.min.js"></script>
<script src="../assets/js/chosen.jquery.min.js"></script>
<script src="../assets/js/spinbox.min.js"></script>
<script src="../assets/js/bootstrap-datepicker.min.js"></script>
<script src="../assets/js/bootstrap-timepicker.min.js"></script>
<script src="../assets/js/moment.min.js"></script>
<script src="../assets/js/daterangepicker.min.js"></script>
<script src="../assets/js/bootstrap-datetimepicker.min.js"></script>
<script src="../assets/js/bootstrap-colorpicker.min.js"></script>
<script src="../assets/js/jquery.knob.min.js"></script>
<script src="../assets/js/autosize.min.js"></script>
<script src="../assets/js/jquery.inputlimiter.min.js"></script>
<script src="../assets/js/jquery.maskedinput.min.js"></script>
<script src="../assets/js/bootstrap-tag.min.js"></script>
<!-- ace scripts -->
<script src="../assets/js/ace-elements.min.js"></script>
<script src="../assets/js/ace.min.js"></script>
<!-- inline scripts related to this page -->
<script>
document.getElementById('btn').addEventListener("click", function(){
this.classList.add("loading");
this.innerHTML = "Loading...";
});
</script>
<style>
.text-on-pannel {
background: #fff none repeat scroll 0 0;
height: auto;
margin-left: 20px;
padding: 3px 5px;
position: absolute;
margin-top: -47px;
border: 1px solid #337ab7;
border-radius: 8px;
}
.panel {
/* for text on pannel */
margin-top: 27px !important;
}
.panel-body {
padding-top: 30px !important;
}
.panel-primary {
border-color: #116bb9;
}
.donate-now {
list-style-type:none;
margin:25px 0 0 0;
padding:0;
}
.donate-now li {
float:left;
margin:0 5px 0 0;
}
.donate-now label {
padding:5px;
border:1px solid #CCC;
cursor:pointer;
}
.donate-now label:hover {
background:#DDD;
}
</style>
</body>
</html>