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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[age_type]","$_POST[Weight]","$_POST[Height]","$_POST[bloodgroup]","$_POST[Nationality]","$_POST[Marital]","$_POST[Religion]","$_POST[Occupation]","$_POST[Familyinc]","$_POST[Education]","$_POST[Passportnm]","$_POST[AadharNu]","$_POST[Referred]","$_POST[Country]","$_POST[State]","$_POST[city]","$_POST[pincode]","$_POST[bloc]","$_POST[nameofinc]","$_POST[Policynm]","$_POST[entered_by]"); } ?> <!DOCTYPE html> <html> <head> <meta charset="utf-8"> <title>PT | Basic</title> <link rel="stylesheet" href="https://www.w3schools.com/w3css/4/w3.css"> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.4.1/jquery.min.js"></script> <script src="https://cdnjs.cloudflare.com/ajax/libs/selectize.js/0.12.6/js/standalone/selectize.min.js" integrity="sha256-+C0A5Ilqmu4QcSPxrlGpaZxJ04VjsRjKu+G82kl5UJk=" crossorigin="anonymous"></script> <link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/selectize.js/0.12.6/css/selectize.bootstrap3.min.css" integrity="sha256-ze/OEYGcFbPRmvCnrSeKbRTtjG4vGLHXgOqsyLFTRjg=" crossorigin="anonymous" /> <link rel="stylesheet" href="select2.min.css" /> <style> .select2-dropdown {top: 22px !important; left: 8px !important;} </style> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <style> table { border-collapse: collapse; border-spacing: 0; width: 100%; } th, td { text-align: left; padding: 8px; } select { width: 25%; } option { width: 25%; } </style> <link rel="stylesheet" href="select2.min.css" /> <style> .select2-dropdown {top: 22px !important; left: 8px !important;} </style> </head> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script> <script> function isNumber(evt) { evt = (evt) ? evt : window.event; var charCode = (evt.which) ? evt.which : evt.keyCode; if (charCode > 31 && (charCode < 48 || charCode > 57)) { alert("Please enter only Numbers."); return false; } return true; } function ValidateNo() { var phoneNo = document.getElementById('numbers'); if (phoneNo.value == "" || phoneNo.value == null) { alert("Please enter your Mobile No."); return false; } if (phoneNo.value.length < 10 || phoneNo.value.length > 10) { alert("Mobile No. is not valid, Please Enter 10 Digit Mobile No."); return false; } return true; } $(function() { $('#expradio').click(function() { $('.txbx').attr('hidden',false); }); $('#frsradio').click(function() { $('.txbx').attr('hidden',true); }); }); $(function() { $('#frsradioage').click(function() { $('.txbxage').attr('hidden',false); }); $('#expradio').click(function() { $('.txbxage').attr('hidden',true); }); }); </script> <script type="text/javascript"> $(document).ready(function() { $('input[type="radio"]').click(function() { var inputValue = $(this).attr("value"); var targetBox = $("." + inputValue); $(".selectt").not(targetBox).hide(); $(targetBox).show(); }); }); </script> <!-- MATERIAL DESIGN ICONIC FONT --> </head> <body> <form name="sub" method="post"> <div class="content-wrapper"> <!-- Content Header (Page header) --> <section class="content-header"> <p> <h3>Add New Patient</h3> <?php include("../dbconnection.php"); require_once('../../DBManager.php'); require_once('../../LoginManager.php'); $narayan=LoginManager::currentUser(); $usertype=LoginManager::getUserTypeByuname("$narayan"); $sql1 ="SELECT * FROM site_users WHERE userno='$usertype'"; $qsql1 = mysqli_query($con,$sql1); if($re = mysqli_fetch_array($qsql1)) { echo"<input type='hidden' name='familyid' value='$re[entered_by]'> "; } ?> <label> Contact Number <span style="color:red">*</span></label> <input type="text" onchange="mobile(this.value)" name="numbers" placeholder="Contact Number" id="numbers" onkeypress="return isNumber(event)" required> <div id='divmb'></div> <label> Name <span style="color:red">*</span></label> <input onclick="ValidateNo();" type="text" name="patientname" style="text-transform: capitalize;" placeholder="Name" onkeyup="this.value = this.value.toUpperCase();" required> <div class="checkbox"> <label> <b>Gender</b> <span style="color:red">*</span></label></div> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="gendor" value="Male" required> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="gendor" value="Female" > <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="gendor" value="Other" > <span>Other </span></div> <label> Fathers/Husband Name <span style="color:red">*</span></label> <input onclick="ValidateNo();" type="text" name="HusbandName" placeholder="Fathers/Husband Name" onkeyup="this.value = this.value.toUpperCase();" style="text-transform: capitalize;" required> <label> Email </label> <input onclick="ValidateNo();" type="email" name="Email" placeholder="Email" class="form-control"> <br><label> Age<span style="color:red">*</span> </label><div class="checkbox"><input type='number' name='dob' id='select' required><select name='age_type' id='select'> <option>Years</option> <option>Month</option> <option>Days</option> </select> </div> <label> Weight </label> <input onclick="ValidateNo();" type="text" name="Weight" placeholder="Weight in Kilogram" class="form-control"> <label> Height </label> <select onclick="ValidateNo();" name="Height" class="form-control"> <option value="0">Select Height</option> <option value="39">1ft 3in / 39 cms </option> <option value="41">1ft 4in / 41 cms </option> <option value="45">1ft 6in / 45 cms </option> <option value="47">1ft 7in / 47 cms </option> <option value="51">1ft 8in / 51 cms </option> <option value="55">1ft 9in / 55 cms </option> <option value="57">1ft 10in / 57 cms </option> <option value="59">1ft 11in / 59 cms </option> <option value="61">2ft 61 cms </option> <option value="65">2ft 1in / 65 cms </option> <option value="67">2ft 2in / 67 cms </option> <option value="69">2ft 3in / 69 cms </option> <option value="73">2ft 4in / 73 cms </option> <option value="75">2ft 5in / 75 cms </option> <option value="77">2ft 6in / 77 cms </option> <option value="79">2ft 7in / 79 cms </option> <option value="83">2ft 8in / 83 cms </option> <option value="85">2ft 9in / 85 cms </option> <option value="87">2ft 10in / 87 cms </option> <option value="89">2ft 11in / 89 cms </option> <option value="93">3ft 93 cms </option> <option value="95">3ft 1in / 95 cms </option> <option value="97">3ft 2in / 97 cms </option> <option value="101">3ft 31in / 101 cms </option> <option value="103">3ft 4in / 103 cms </option> <option value="105">3ft 5in / 105 cms </option> <option value="107">3ft 6in / 107 cms </option> <option value="111">3ft 7in / 111 cms </option> <option value="113">3ft 8in / 113 cms </option> <option value="115">3ft 9in / 115 cms </option> <option value="117">3ft 10in / 117 cms </option> <option value="121">3ft 11in / 121 cms </option> <option value="123">4ft 123 cms </option> <option value="125">4ft 1in / 125 cms </option> <option value="127">4ft 2in / 127 cms </option> <option value="131">4ft 3in / 131 cms </option> <option value="133">4ft 4in / 133 cms </option> <option value="135">4ft 5in / 135 cms </option> <option value="137" > >3ft 10in / 137 cms</option> <option value="139" >4ft 7in / 139 cms</option> <option value="142" >4ft 8in / 142 cms</option> <option value="144" >4ft 9in / 144 cms</option> <option value="147" >4ft 10in / 147 cms</option> <option value="149" >4ft 11in / 149 cms</option> <option value="152" >5ft / 152 cms</option> <option value="154" >5ft 1in / 154 cms</option> <option value="157" >5ft 2in / 157 cms</option> <option value="160" >5ft 3in / 160 cms</option> <option value="162" >5ft 4in / 162 cms</option> <option value="165" >5ft 5in / 165 cms</option> <option value="167" >5ft 6in / 167 cms</option> <option value="170" >5ft 7in / 170 cms</option> <option value="172" >5ft 8in / 172 cms</option> <option value="175" >5ft 9in / 175 cms</option> <option value="177" >5ft 10in / 177 cms</option> <option value="180" >5ft 11in / 180 cms</option> <option value="182" >6ft / 182 cms</option> <option value="185" >6ft 1in / 185 cms</option> <option value="187" >6ft 2in / 187 cms</option> <option value="190" >6ft 3in / 190 cms</option> <option value="193" >6ft 4in / 193 cms</option> <option value="195" >6ft 5in / 195 cms</option> <option value="198" >6ft 6in / 198 cms</option> <option value="200" >6ft 7in / 200 cms</option> <option value="203" >6ft 8in / 203 cms</option> <option value="205" >6ft 9in / 205 cms</option> <option value="208" >6ft 10in / 208 cms</option> <option value="210" >6ft 11in / 210 cms</option> <option value="213" >7ft / 213 cms</option> </select> <label> Blood Group </label> <select name="bloodgroup" class="form-control" > <option value="">Blood Group</option> <option value='A+'>A+</option><option value='A-'>A-</option><option value='B+'>B+</option><option value='B-'>B-</option><option value='O+'>O+</option><option value='O-'>O-</option><option value='AB+'>AB+</option><option value='AB-'>AB-</option> </select> <label> Nationality </label> <select name="Nationality" class="form-control"><option value="0">Nationality</option><option value="Indian" style="color:#004F00">Indian</option><option value="222" style="color:#004F00">United States of America</option><option value="220" style="color:#004F00">United Arab Emirates</option><option value="221" style="color:#004F00">United Kingdom</option><option value="13" style="color:#004F00">Australia</option><option value="189" style="color:#004F00">Singapore</option><option value="39" style="color:#004F00">Canada</option><option value="173" style="color:#004F00">Qatar</option><option value="114" style="color:#004F00">Kuwait</option><option value="161" style="color:#004F00">Oman</option><option value="17" style="color:#004F00">Bahrain</option><option value="185" style="color:#004F00">Saudi Arabia</option><option value="129" style="color:#004F00">Malaysia</option><option value="80" style="color:#004F00">Germany</option><option value="153" style="color:#004F00">New Zealand</option><option value="73" style="color:#004F00">France</option><option value="102" style="color:#004F00">Ireland</option><option value="203" style="color:#004F00">Switzerland</option><option value="193" style="color:#004F00">South Africa</option><option value="195" style="color:#004F00">Sri Lanka</option><option value="99" style="color:#004F00">Indonesia</option><option value="149" style="color:#004F00">Nepal</option><option value="162" style="color:#004F00">Pakistan</option><option value="18" style="color:#004F00">Bangladesh</option><option value="1" style="color:#004F00">Afghanistan</option></select> <label> Marital status </label> <select name="Marital" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single">Single</option> <option value="Married" label="Married">Married</option> <option value="Widowed">Widowed</option> <option value="divorced" label="divorced">Divorced</option> </select> <label> Religion </label> <select name="Religion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu">Hindu</option> <option value="Muslim" label="Muslim">Muslim</option> <option value="Christian" label="Christian">Christian</option> <option value="Sikh" label="Sikh">Sikh</option> <option value="Parsi" label="Parsi">Parsi</option> <option value="Jain" label="Jain">Jain</option> <option value="Buddhist" label="Buddhist">Buddhist</option> <option value="Jewish" label="Jewish">Jewish</option> <option value="No Religion" label="No Religion">No Religion</option> <option value="Spiritual - not religious" label="Spiritual">Spiritual</option> <option value="Other" label="Other">Other</option> </select> <label> Occupation </label> <select name="Occupation" class="form-control" > <option value="" disabled selected>Occupation </option> <option value="Business Owner">Business Owner</option> <option value="Director ,Chief Executive & Senior officers">Director ,Chief Executive & Senior officers</option> <option value="I.T Professionals">I.T Professionals </option> <option value="Medical professionals">Medical professionals</option> <option value="Bank Professional ">Bank Professional </option> <option value="Services and sales">Services and sales</option> <option value="Agricultural workers">Agricultural workers</option> <option value="Defense Services">Defense Services</option> <option value="Homemakers">Homemakers</option> <option value="Student">Student</option> <option value="Other">Other</option> </select> <label> Family income </label> <select name="Familyinc" class="form-control"> <option value="0">- Family Income -</option> <option value="3">0 - 1 Lakh</option><option value="1 - 2 Lakhs">1 - 2 Lakhs</option><option value="2 - 3 Lakhs">2 - 3 Lakhs</option><option value="3 - 4 Lakhs">3 - 4 Lakhs</option><option value="4 - 5 Lakhs">4 - 5 Lakhs</option><option value="5 - 6 Lakhs">5 - 6 Lakhs</option><option value="6 - 7 Lakhs">6 - 7 Lakhs</option><option value="7 - 8 Lakhs">7 - 8 Lakhs</option><option value="8 - 9 Lakhs">8 - 9 Lakhs</option><option value="9 - 10 Lakhs">9 - 10 Lakhs</option><option value="10 - 12 Lakhs">10 - 12 Lakhs</option><option value="12 - 14 Lakhs">12 - 14 Lakhs</option><option value="14 - 16 Lakhs">14 - 16 Lakhs</option><option value="16 - 18 Lakhs">16 - 18 Lakhs</option><option value="18 - 20 Lakhs">18 - 20 Lakhs</option><option value="20 - 25 Lakhs">20 - 25 Lakhs</option><option value="19">25 - 30 Lakhs</option><option value="25 - 30 Lakhs">30 - 35 Lakhs</option><option value="35 - 40 Lakhs">35 - 40 Lakhs</option><option value="40 - 45 Lakhs">40 - 45 Lakhs</option><option value="45 - 50 Lakhs">45 - 50 Lakhs</option><option value="50 - 60 Lakhs">50 - 60 Lakhs</option><option value="60 - 70 Lakhs">60 - 70 Lakhs</option><option value="70 - 80 Lakhs">70 - 80 Lakhs</option><option value="80 - 90 Lakhs">80 - 90 Lakhs</option><option value="90 Lakhs - 1 Crore">90 Lakhs - 1 Crore</option><option value="1 Crore & Above">1 Crore & Above</option> </select> <label> Education Qualification </label> <select name="Education" class="form-control" > <option value="" disabled selected> Education Qualification</option> <option value='Doctrate'>Doctorate</option> <option value='Post Graduation'>Post Graduation</option> <option value='Graduation'>Graduation</option> <option value='Diploma'>Diploma</option> <option value='Higher Secondary School / High School'>Higher Secondary School / High School</option> <option value='None Of Above'>None Of Above</option> </select> <label> Passport Number</label> <input type="text" name="Passportnm" placeholder="Passport Number (In case of Foreign citizen)" > <label> Aadhar Number </label> <input type="text" name="AadharNu" placeholder="Aadhar Number" class="form-control" > <!-- SECTION 5 --> <label>Country <span style="color:red">*</span></label> <select class="form-control" name="Country" id="country" required> <option value="" disabled selected>Country</option> <?php include("../dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> <label>State Name <span style="color:red">*</span></label> <select class="form-control" name="State" id="state" required> <option value="">Select country first</option> </select> <label>Districts Name <span style="color:red">*</span></label> <div id=''> <select class="form-control" name="city" id="city" required> <option value="">Select state first</option> </select> </div> <label>Pincode </label> <input type="text" name="pincode" placeholder="Pincode" class="form-control" > <label> Address </label> <input type="text" name="bloc" placeholder="Address Line 1" class="form-control" > <label>Insurance Company Name </label> <select name="nameofinc" class="form-control"> <option value="">Insurance Company Name </option> <?php include("../dbconnection.php"); $sqlpatient1 = "SELECT * FROM tpa_insurance"; $qsqlpatient1 = mysqli_query($con,$sqlpatient1); while($rsn = mysqli_fetch_array($qsqlpatient1)) { echo "<option value='$rsn[id]'>$rsn[Name]</option>"; } ?> </td> </select> <label>Policy Number </label> <input type="text" name="Policynm" placeholder="Policy Number" class="form-control"> <button id="btn" type="submit" name="sub">Submit</button> </form> <script> document.getElementById('btn').addEventListener("click", function(){ this.classList.add("loading"); this.innerHTML = "Loading..."; }); </script> <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 src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.0/jquery.min.js"></script> <script> $(document).ready(function(){ $('#country').on('change', function(){ var countryID = $(this).val(); if(countryID){ $.ajax({ type:'POST', url:'../ajaxData.php', data:'country_id='+countryID, success:function(html){ $('#state').html(html); $('#city').html('<option value="">Select state first</option>'); } }); }else{ $('#state').html('<option value="">Select country first</option>'); $('#city').html('<option value="">Select state first</option>'); } }); $('#state').on('change', function(){ var stateID = $(this).val(); if(stateID){ $.ajax({ type:'POST', url:'../ajaxData.php', data:'state_id='+stateID, success:function(html){ $('#city').html(html); } }); }else{ $('#city').html('<option value="">Select state first</option>'); } }); }); $(document).ready(function () { $('select').selectize({ sortField: 'text' }); }); </script> <script> $(document).ready(function () { $('select12').selectize({ sortField: 'text' }); }); </script>