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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; } </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; } </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> <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" 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> <label> Fathers/Husband Name <span style="color:red">*</span></label> <input onclick="ValidateNo();" type="text" name="HusbandName" placeholder="Fathers/Husband Name" required> <label> Email </label> <input onclick="ValidateNo();" type="email" name="Email" placeholder="Email" class="form-control"> <label> Age <span style="color:red">*</span> </label> <input onclick="ValidateNo();" type="number" name="dob" required> <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="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 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="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="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='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)" > <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 class='select2' id="select12-state" name="nameofinc"> <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>