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<?php session_start();
include("menu.php");
include("dbconnection.php");
//Code for Registration
if(isset($_POST['sub']))
{
$Dailyact=$_POST['Dailyact'];
$adNone=$_POST['adNone'];
$Alcohol=$_POST['Alcohol'];
$Smoking=$_POST['Smoking'];
$Tobacco=$_POST['Tobacco'];
$fmNone=$_POST['fmNone'];
$fmDiabetes=$_POST['fmDiabetes'];
$fmThyroid=$_POST['fmThyroid'];
$fmHeart=$_POST['fmHeart'];
$fmHypertension=$_POST['fmHypertension'];
$fmDepression=$_POST['fmDepression'];
$fmAnemia=$_POST['fmAnemia'];
$fmThalassemia=$_POST['fmThalassemia'];
$fmHIV=$_POST['fmHIV'];
$None=$_POST['None'];
$Diabetes=$_POST['Diabetes'];
$Diabetesst=$_POST['Diabetesst'];
$Thyroid=$_POST['Thyroid'];
$Thyroidst=$_POST['Thyroidst'];
$PCOD=$_POST['PCOD'];
$PCODst=$_POST['PCODst'];
$Cholesterol=$_POST['Cholesterol'];
$Cholesterolst=$_POST['Cholesterolst'];
$PhysicalInjury=$_POST['PhysicalInjury'];
$PhysicalInjuryst=$_POST['PhysicalInjuryst'];
$HeartCondition=$_POST['HeartCondition'];
$HeartConditionst=$_POST['HeartConditionst'];
$Hypertension=$_POST['Hypertension'];
$Hypertensionst=$_POST['Hypertensionst'];
$Depression=$_POST['Depression'];
$Depressionst=$_POST['Depressionst'];
$Physicallychallenged=$_POST['Physicallychallenged'];
$Physicallychallengedst=$_POST['Physicallychallengedst'];
$Mentallychallenged=$_POST['Mentallychallenged'];
$Mentallychallengedst=$_POST['Mentallychallengedst'];
$TerminallyIll=$_POST['TerminallyIll'];
$TerminallyIllst=$_POST['TerminallyIllst'];
$Dependency=$_POST['Dependency'];
$Modn=$_POST['Modn'];
$Level=$_POST['Level'];
$msg=mysqli_query($con,"insert into medicalcon(Dailyact,adNone,Alcohol,Smoking,Tobacco,fmNone,fmDiabetes,fmThyroid,fmHeart,fmHypertension,fmDepression,fmAnemia,fmThalassemia,fmHIV,None,Diabetes,Diabetesst,Thyroid,Thyroidst,PCOD,PCODst,Cholesterol,Cholesterolst,PhysicalInjury,PhysicalInjuryst,HeartCondition,HeartConditionst,Depression,Depressionst,Physicallychallenged,Physicallychallengedst,Mentallychallenged,Mentallychallengedst,TerminallyIll,TerminallyIllst,Dependency,Modn,Level) values('$Dailyact','$adNone','$Alcohol','$Smoking','$Tobacco','$fmNone','$fmDiabetes','$fmThyroid','$fmHeart','$fmHypertension','$fmDepression','$fmAnemia','$fmThalassemia','$fmHIV','$None','$Diabetes','$Diabetesst','$Thyroid','$Thyroidst','$PCOD','$PCODst','$Cholesterol','$Cholesterolst','$PhysicalInjury','$PhysicalInjuryst','$HeartCondition'
,'$HeartConditionst','$Depression','$Depressionst','$Physicallychallenged','$Physicallychallengedst','$Mentallychallenged','$Mentallychallengedst','$TerminallyIll','$TerminallyIllst','$Dependency','$Modn','$Level')");
if($msg)
{
echo "<script>alert('Register successfully');</script>";
}
}
?>
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<title>PT | Basic</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<style>
table {
border-collapse: collapse;
border-spacing: 0;
width: 100%;
}
th, td {
text-align: left;
padding: 8px;
}
</style>
<script>
function myFunction() {
var checkBox = document.getElementById("myCheck");
var text = document.getElementById("text");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction1() {
var checkBox = document.getElementById("myCheck1");
var text = document.getElementById("text1");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction2() {
var checkBox = document.getElementById("myCheck2");
var text = document.getElementById("text2");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction3() {
var checkBox = document.getElementById("myCheck3");
var text = document.getElementById("text3");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction4() {
var checkBox = document.getElementById("myCheck4");
var text = document.getElementById("text4");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction5() {
var checkBox = document.getElementById("myCheck5");
var text = document.getElementById("text5");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction6() {
var checkBox = document.getElementById("myCheck6");
var text = document.getElementById("text6");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction7() {
var checkBox = document.getElementById("myCheck7");
var text = document.getElementById("text7");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction8() {
var checkBox = document.getElementById("myCheck8");
var text = document.getElementById("text8");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction9() {
var checkBox = document.getElementById("myCheck9");
var text = document.getElementById("text9");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
function myFunction10() {
var checkBox = document.getElementById("myCheck10");
var text = document.getElementById("text10");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
</script>
<script>
var stateObject = {
"India": { "UttarPradesh": ["Agra","Aligarh","Allahabad","Ambedkar Nagar","Amethi (Chatrapati Sahuji Mahraj Nagar)", "Amroha (J.P. Nagar)","Auraiya", "Azamgarh", "Baghpat", "Bahraich", "Ballia", "Balrampur", "Banda", "Barabanki", "Bareilly", "Basti", "Bhadohi", "Bijnor", "Budaun", "Bulandshahr", "Chandauli", "Chitrakoot", "Deoria", "Etah", "Etawah", "Faizabad", "Farrukhabad", "Fatehpur", "Firozabad", "Gautam Buddha Nagar", "Ghaziabad", "Ghazipur", "Gonda", "Gorakhpur", "Hamirpur", "Hapur", "(Panchsheel Nagar) Hardoi", "Hathras","Jalaun", "Jaunpur", "Jhansi", "Kannauj", "Kanpur", "Dehat", "Kanpur Nagar", "Kanshiram Nagar(Kasganj)", "Kaushambi", "Kushinagar (Padrauna)", "Lakhimpur - Kheri", "Lalitpur","Lucknow","Maharajganj", "Mahoba", "Mainpuri", "Mathura", "Mau", "Meerut", "Mirzapur", "Moradabad", "Muzaffarnagar", "Pilibhit", "Prayagraj", "Pratapgarh", "RaeBareli", "Rampur","Saharanpur", "Sambhal (Bhim Nagar)", "Sant Kabir Nagar", "Shahjahanpur", "Shamali (Prabuddh Nagar)", "Shravasti", "Siddharth Nagar", "Sitapur", "Sonbhadra", "Sultanpur", "Unnao", "Varanasi"],
"Bihar": ["Araria", "Arwal", "Aurangabad", "Banka", "Begusarai", "Bhagalpur", "Bhojpur", "Buxar", "Darbhanga","Gaya","Gopalganj","Jamui", "Jehanabad","Kaimur (Bhabua)","Katihar", "Khagaria","Kishanganj","khisarai" ,"Madhepura","Madhubani","Munger","Muzaffarpur","Nalanda","Nawada", "Pashchim", "Champaran (West Champaran)","Patna","Purba", "Champaran (East Champaran)","Purnia","Rohtas","Saharsa","Samastipur","Saran","Sheikhpura", "Sheohar","Sitamarhi","Siwan","Supaul","Vaishali"],
"Uttarakhand": ["Almora","Bageshwar","Chamoli","Champawat","Dehradun", "Haridwar","Nainital", "Pauri","Pithoragarh", "Rudraprayag","Tehri","Udham Singh Nagar","Uttarkashi"],
},
"Australia": {
"South Australia": ["Dunstan", "Mitchell"],
"Victoria": ["Altona", "Euroa"]
}, "Canada": {
"Alberta": ["Acadia", "Bighorn"],
"Columbia": ["Washington", ""]
},
}
window.onload = function () {
var countySel = document.getElementById("countySel"),
stateSel = document.getElementById("stateSel"),
districtSel = document.getElementById("districtSel");
for (var country in stateObject) {
countySel.options[countySel.options.length] = new Option(country, country);
}
countySel.onchange = function () {
stateSel.length = 1; // remove all options bar first
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
for (var state in stateObject[this.value]) {
stateSel.options[stateSel.options.length] = new Option(state, state);
}
}
countySel.onchange(); // reset in case page is reloaded
stateSel.onchange = function () {
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
var district = stateObject[countySel.value][this.value];
for (var i = 0; i < district.length; i++) {
districtSel.options[districtSel.options.length] = new Option(district[i], district[i]);
}
}
}
</script>
<!-- MATERIAL DESIGN ICONIC FONT -->
</head>
<body>
<form name="sub" method="post">
<?php
$sqlpatient= "SELECT * FROM patient WHERE familyid='$_GET[familyid]'";
$qsqlpatient = mysqli_query($con,$sqlpatient);
while($rspatient=mysqli_fetch_array($qsqlpatient))
{
echo "<input type='hidden' name='familyid' id='familyid' value='$rspatient[familyid]'></td>";
}
?>
<?php
$sqlpatient= "SELECT * FROM admin WHERE adminid='$_GET[adminid]'";
$qsqlpatient = mysqli_query($con,$sqlpatient);
while($rspatient=mysqli_fetch_array($qsqlpatient))
{
echo "<input type='hidden' name='adminid' id='adminid' value='$rspatient[adminid]'></td>";
}
?> <div class="content-wrapper">
<!-- Content Header (Page header) -->
<section class="content-header">
<fieldset>
<legend>
<p>
<h3 align="center">Medical Assessment</h3>
<div class="form-holder">
<h5 align="left">Daily Activity</h5>
<select name="Dailyact" id="cars" class="form-control">
<option value="" disabled selected>Daily Activity </option>
<option value="Sedentary (Little or No Exercise)">Sedentary
<br><br>(Little or No Exercise) </option>
<option value="Lightly Active (Light Exercise ">Lightly Active (Light Exercise /Sports 1-3 Days a week)</option>
<option value="Moderately Active (Moderate Exercise">Moderately Active (Moderate Exercise /Sports 3-5 days in a week)</option>
<option value="Moderately Active (Moderate Exercise">Very Active (Hard Exercise/Sports 6-7 days in a week) </option>
</select>
</div>
<h3 align="center">Addiction</h1>
<div class="form-row"><div class="form-holder">
<input name="adNone" type="checkbox">
<span style="font-size:18px;">None</span>
</div></div>
<div class="form-row"> <div class="form-holder">
<input name="Alcohol" type="checkbox">
<span style="font-size:18px;"> Alcohol </span>
</div></div>
<div class="form-row"> <div class="form-holder">
<input name="Smoking" type="checkbox">
<span style="font-size:18px;"> Smoking</span>
</div></div>
<div class="form-row"> <div class="form-holder">
<input name="Tobacco" type="checkbox">
<span style="font-size:18px;"> Tobacco</span>
</div></div>
<h3 align="center">Family History </h1>
<div class="form-row">
<div class="form-holder">
<input name="fmNone" type="checkbox">
<span style="font-size:18px;"> None</h2></span>
</div></div>
<div class="form-row"><div class="form-holder">
<input name="fmDiabetes" type="checkbox">
<span style="font-size:18px;"> Diabetes </span>
</div> </div>
<div class="form-row"><div class="form-holder">
<input name="fmThyroid" type="checkbox">
<span style="font-size:18px;"> Thyroid</span>
</div></div>
<div class="form-row">
<div class="form-holder">
<input name="fmHeart" type="checkbox">
<span style="font-size:18px;"> Heart Condition</span>
</div> </div>
<div class="form-row"><div class="form-holder">
<input name="fmHypertension" type="checkbox">
<span style="font-size:18px;"> Hypertension</span>
</div></div>
<div class="form-row">
<div class="form-holder">
<input name="fmDepression" type="checkbox">
<span style="font-size:18px;"> Depression</span>
</div></div>
<div class="form-row"> <div class="form-holder">
<input name="fmAnemia" type="checkbox">
<span style="font-size:18px;"> Anemia</span>
</div></div>
<div class="form-row">
<div class="form-holder">
<input name="fmThalassemia" type="checkbox">
<span style="font-size:18px;"> Thalassemia</span>
</div></div>
<div class="form-row">
<div class="form-holder">
<input name="fmHIV" type="checkbox">
<span style="font-size:18px;"> HIV</span>
</div></div>
<h3 align="center">Medical Condition </h1>
</legend> <div class='account-details'>
<div>
<div>
<input name="None" type="checkbox">
<span style="font-size:18px;"> None</h2></span>
</div>
<div>
<input id="myCheck" name="Diabetes" onclick="myFunction()" type="checkbox">
<span style="font-size:18px;">Diabetes</span>
</div>
<div>
<select id="text" name="Diabetesst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck1" name="Thyroid" onclick="myFunction1()" type="checkbox">
<span style="font-size:18px;">Thyroid</span>
</div>
<div>
<select id="text1" name="Thyroidst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck2" name="PCOD" onclick="myFunction2()" type="checkbox">
<span style="font-size:18px;"> PCOD</span>
</div>
<div>
<select name="PCODst" id="text2" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck3" name="Cholesterol" onclick="myFunction3()" type="checkbox">
<span style="font-size:18px;">Cholesterol</span>
</div>
<div>
<select name="Cholesterolst" id="text3" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div> <div>
<input id="myCheck4" name="PhysicalInjury" onclick="myFunction4()" type="checkbox">
<span style="font-size:18px;">Physical Injury</span>
</div>
<div>
<select id="text4" name="PhysicalInjuryst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select> </div>
<div>
<input id="myCheck5" name="HeartCondition" onclick="myFunction5()" type="checkbox">
<span style="font-size:18px;">Heart Condition</span>
</div>
<div>
<select id="text5" name="HeartConditionst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck6" name="Hypertension" onclick="myFunction6()" type="checkbox">
<span style="font-size:18px;"> Hypertension</span>
</div>
<div>
<select name="Hypertensionst" id="text6" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck7" name="Depression" onclick="myFunction7()" type="checkbox">
<span style="font-size:18px;"> Depression</span>
</div>
<div>
<select id="text7" name="Depressionst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck8" name="Physicallychallenged" onclick="myFunction8()" type="checkbox">
<span style="font-size:18px;"> Physically challenged</span>
</div>
<div>
<select id="text8" name="Physicallychallengedst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck9" name="Mentallychallenged" onclick="myFunction9()" type="checkbox">
<span style="font-size:18px;"> Mentally challenged</span>
</div>
<div>
<select id="text9" name="Mentallychallengedst" style="display:none" class="form-control">
<option value="" disabled selected>Clinical Status </option>
<option value="Confirmed">Confirmed </option>
<option value="Active">Active </option>
<option value="Cured">Cured</option>
</select>
</div>
<div>
<input id="myCheck10" name="TerminallyIll" onclick="myFunction10()" type="checkbox">
<span style="font-size:18px;"> Terminally Ill </span>
</div>
<div>
<p id="text10" style="display:none" >
<input type="text" name="terSpecify" class="form-control" placeholder="Specify">
<br>
</p> </div>
<div class="form-holder">
<label> Dependency</label>
<select name="Dependency" class="form-control">
<option value="" disabled selected>Dependency </option>
<option value="Independent">Independent</option>
<option value="Partially Dependent">Partially Dependent</option>
<option value="Completely Dependent">Completely Dependent </option>
</select>
</div>
<div class="form-holder">
<label> Mode of Movement </label>
<select name="Modn" class="form-control">
<option value="" disabled selected>Mode of Movement </option>
<option value="Independent">Ambulatory</option>
<option value="Wheel chair">Wheel chair</option>
<option value="Stretcher">Stretcher </option>
<option value="Physical Support">Physical Support </option>
</select>
</div>
<div class="form-holder">
<label> Level of Consciousness </label>
<select name="Level" class="form-control">
<option value="" disabled selected>Level of Consciousness </option>
<option value="Conscious">Conscious</option>
<option value="Semi Conscious">Semi Conscious</option>
<option value="Un-conscious ">Un-conscious </option>
</select>
</div>
<!-- SECTION 4 -->
<div style="overflow-x:auto;">
<table>
<th>Drug</th>
<th>Dose</th>
<th>Route</th>
<th>Frequency</th>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
<tr>
<td><input type="text" class="form-control" placeholder="Drug Name"></td>
<td><input type="text" class="form-control" placeholder="Dose"></td>
<td> <select class="form-control" name="Route">
<option value="" disabled selected>Route </option>
<option value="Orally">Orally</option>
<option value="IV/IM">IV/IM</option>
<option value="Sublingually/ Buccally">Sublingually/ Buccally</option>
<option value="Vaginally">Vaginally</option>
<option value="Ocular/ Otic"> Ocular/ Otic </option>
<option value="Nasally">Nasally</option>
<option value="Inhalation/Nebulization">Inhalation/Nebulization</option>
<option value="cutaneously/systemic">cutaneously/systemic</option>
<option value="transdermally">transdermally</option>
</select></td>
<td><select class="form-control" name="Frequency">
<option value="" disabled selected>Frequency </option>
<option value="OD (Once Daily)">OD (Once Daily)</option>
<option value="BID/b.i.d. (twice a day)">BID/b.i.d. (twice a day)</option>
<option value="TID/t.id. (three times a day)">TID/t.id. (three times a day)</option>
<option value="QID/q.i.d. (four times a day)">QID/q.i.d. (four times a day)</option>
<option value="QHS (every bedtime)"> QHS (every bedtime) </option>
<option value="Q4h (every 4 hours)">Q4h (every 4 hours)</option>
<option value="Q4-6h (every 4 to 6 hours)">Q4-6h (every 4 to 6 hours)</option>
<option value="QWK (every week)">QWK (every week)</option>
</select></td>
</tr>
</table>
</div>
<button type="submit" name="sub">Submit</button>
</div></form>
</body>
</html>