| Şuanki Dizin: /home/wwwdreamtechnolo/public_html/kitchenfoodrecipes.com/disha/disha-foundation/ |
| Şuanki Dosya : /home/wwwdreamtechnolo/public_html/kitchenfoodrecipes.com/disha/disha-foundation/new_admission.php |
<?php
require_once('lib/function.php');
$db = new login_function();
if(isset($_SESSION['current_login_admin']))
{
$current_login_admin = $_SESSION['current_login_admin'];
}
if(isset($_GET['update_id']))
{
$update_id = $_GET['update_id'];
$_SESSION['current_update_id'] = $update_id;
}
else if(isset($_SESSION['current_update_id']))
{
$update_id = $_SESSION['current_update_id'];
}
$contact_no_error = "";
$image_error = "";
$succ_flag = 0;
$flag = 0;
//$logo = "";
$var_name ="";
$var_address ="";
$var_mobile_no="";
$var_user_type ="";
$var_password ="";
$var_user_type_error ="";
if(isset($_SESSION['current_login_admin']))
{
$email = $_SESSION['current_login_admin'];
}
if(isset($_POST['add']))
{
$date_of_admission = $_POST['date_of_admission'];
$center = $_POST['center'];
$name_patient = $_POST['name_patient'];
$gender = $_POST['gender'];
$address = $_POST['address'];
$is_rural = $_POST['is_rural'];
$city = $_POST['city'];
$state = $_POST['state'];
$pin = $_POST['pin'];
$phone = $_POST['phone'];
$mobile = $_POST['mobile'];
$email = $_POST['email'];
$date_of_birth = $_POST['date_of_birth'];
$age = $_POST['age'];
$religion = $_POST['religion'];
$education_qualification = $_POST['education_qualification'];
$occupation = $_POST['occupation'];
$incone_per_month = $_POST['incone_per_month'];
$family = $_POST['family'];
$marital_status = $_POST['marital_status'];
$living_arrangements = $_POST['living_arrangements'];
$name_family_member = $_POST['name_family_member'];
$address_family_mem = $_POST['address_family_mem'];
$phone_family = $_POST['phone_family'];
$mobile_family = $_POST['mobile_family'];
$email_family = $_POST['email_family'];
$referred_by = $_POST['referred_by'];
$reason_of_addiction = $_POST['reason_of_addiction'];
$type_addiction = $_POST['type_addiction'];
$jaundice = $_POST['jaundice'];
$malena = $_POST['malena'];
$hemelemesis = $_POST['hemelemesis'];
$convulsion = $_POST['convulsion'];
$ascitis = $_POST['ascitis'];
$chronic_pedal_oedems = $_POST['chronic_pedal_oedems'];
$psychiatric_problem = $_POST['psychiatric_problem'];
$heart_attack = $_POST['heart_attack'];
$shock = $_POST['shock'];
$tia = $_POST['tia'];
$kochs = $_POST['kochs'];
$ht = $_POST['ht'];
$dm = $_POST['dm'];
$aadhar_no = $_POST['aadhar_no'];
$pratidnya_name = $_POST['pratidnya_name'];
$pratidnya_address = $_POST['pratidnya_address'];
$pratidnya_mobile = $_POST['pratidnya_mobile'];
$pratidnya_age = $_POST['pratidnya_age'];
$status = 'Admitted';
$relation = $_POST['relation'];
$totalamount = 0;
$dcotor_name = $_POST['dcotor_name'];
$discharge_date = $_POST['discharge_date'];
$samupdeshk_name = $_POST['samupdeshk_name'];
$present_coplaints =$_POST['present_coplaints'];
$other_findings =$_POST['other_findings'];
$year_of_addiction =$_POST['year_of_addiction'];
$patient_marathi =$_POST['patient_marathi'];
$realtive_age =$_POST['realtive_age'];
if( $var_user_type == "Select")
{
$var_user_type_error = "please select user type";
$flag = 1;
}
if($flag==0)
{
$db->add_admission_form($date_of_admission,$center,$name_patient,$gender,$address,$is_rural,$city,$state,$pin,$phone,$mobile,$email,$date_of_birth,$age,$religion,$education_qualification,$occupation,$incone_per_month,$family,$marital_status,$living_arrangements,$name_family_member,$address_family_mem,$phone_family,$mobile_family,$email_family,$referred_by,$reason_of_addiction,$type_addiction,$jaundice,$malena,$hemelemesis,$convulsion,$ascitis,$chronic_pedal_oedems,$psychiatric_problem,$heart_attack,$shock,$tia,$kochs,$ht,$dm,$aadhar_no,$pratidnya_name,$pratidnya_address,$pratidnya_mobile,$pratidnya_age,$status,$relation,$totalamount,$dcotor_name,$discharge_date,$samupdeshk_name,$present_coplaints,$other_findings,$year_of_addiction,$patient_marathi,$realtive_age);
$succ_flag = 1 ;
}
}
$report_details = $db->get_all_admission_info($update_id);
if(!empty($report_details))
{
$counter =0;
foreach($report_details as $record)
{
$id = $report_details[$counter][0];
$date_of_admission = $report_details[$counter][1];
$center = $report_details[$counter][2];
$name_patient = $report_details[$counter][3];
$gender = $report_details[$counter][4];
$address = $report_details[$counter][5];
$is_rural = $report_details[$counter][6];
$city = $report_details[$counter][7];
$state = $report_details[$counter][8];
$pin = $report_details[$counter][9];
$phone = $report_details[$counter][10];
$mobile = $report_details[$counter][11];
$email = $report_details[$counter][12];
$date_of_birth = $report_details[$counter][13];
$age = $report_details[$counter][14];
$religion = $report_details[$counter][15];
$education_qualification = $report_details[$counter][16];
$occupation = $report_details[$counter][17];
$incone_per_month = $report_details[$counter][18];
$family = $report_details[$counter][19];
$marital_status = $report_details[$counter][20];
$living_arrangements = $report_details[$counter][21];
$name_family_member = $report_details[$counter][22];
$address_family_mem = $report_details[$counter][23];
$phone_family = $report_details[$counter][24];
$mobile_family = $report_details[$counter][25];
$email_family = $report_details[$counter][26];
$referred_by = $report_details[$counter][27];
$reason_of_addiction = $report_details[$counter][28];
$type_addiction = $report_details[$counter][29];
$jaundice = $report_details[$counter][31];
$malena = $report_details[$counter][32];
$malenamalena = $report_details[$counter][33];
$convulsion = $report_details[$counter][34];
$ascitis = $report_details[$counter][35];
$chronic_pedal_oedems = $report_details[$counter][36];
$psychiatric_problem = $report_details[$counter][37];
$heart_attack = $report_details[$counter][38];
$shock = $report_details[$counter][39];
$tia = $report_details[$counter][40];
$kochs = $report_details[$counter][41];
$ht = $report_details[$counter][42];
$dm = $report_details[$counter][43];
$aadhar_no = $report_details[$counter][44];
$pratidnya_name = $report_details[$counter][45];
$pratidnya_address = $report_details[$counter][46];
$pratidnya_mobile = $report_details[$counter][47];
$pratidnya_age = $report_details[$counter][48];
$date = $report_details[$counter][49];
$time = $report_details[$counter][50];
$totalamount = $report_details[$counter][51];
$dcotor_name = $report_details[$counter][52];
$discharge_date = $report_details[$counter][53];
$samupdeshk_name = $report_details[$counter][54];
$present_coplaints = $report_details[$counter][55];
$other_findings = $report_details[$counter][56];
$year_of_addiction = $report_details[$counter][57];
$relation = $report_details[$counter][58];
$patient_marathi = $report_details[$counter][59];
$realtive_age = $report_details[$counter][60];
}
}
?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width initial-scale=1.0">
<title>Admission Form</title>
<!-- GLOBAL MAINLY STYLES-->
<link href="css/bootstrap.min.css" rel="stylesheet" />
<link href="css/font-awesome.min.css" rel="stylesheet" />
<link href="css/line-awesome.min.css" rel="stylesheet" />
<link href="css/themify-icons.css" rel="stylesheet" />
<link href="css/animate.min.css" rel="stylesheet" />
<link href="css/toastr.min.css" rel="stylesheet" />
<link href="css/bootstrap-select.min.css" rel="stylesheet" />
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.8.2/css/all.css">
<!-- THEME STYLES-->
<link href="css/main.min.css" rel="stylesheet" />
<link href="datatable/datatables.min.css" rel="stylesheet" />
<link href="css/animate.css" rel="stylesheet" type="text/css" media="all">
<script src="js/wow.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.6.0/jquery.min.js"></script>
<script type="text/javascript" src="https://translate.google.com/translate_a/element.js?cb=googleTranslateElementInit"></script>
<script>
function validateForm() {
var a = document.forms["myForm"]["customer_name"].value;
var c = document.forms["myForm"]["primary_contact"].value;
if (a == "") {
alert("Enter Customer Name");
return false;
}
if (c == "") {
alert("Enter Mobile Number");
return false;
}
}
</script>
</head>
<body class="fixed-navbar">
<div class="page-wrapper" style="min-height:500px;">
<?php include('header.php'); ?>
<?php include('side-bar.php'); ?>
<div class="content-wrapper">
<div class="row" style="padding:0px; margin:0px; margin-top:15px; border-radius:15px;">
<?php
if($succ_flag == 1)
{
?>
<div class="alert alert-success">
PATIENT DETAILS Added Successfully.
</div>
<?php
}
if($succ_flag == 2)
{
?>
<div class="alert alert-warning">
Failed to Add.
</div>
<?php
}
?>
<div class="ibox" style="border-radius:5px; padding:7px;">
<form class="form-pink" method="post" action="<?php echo $_SERVER['PHP_SELF']?>" name="myForm" onsubmit="return validateForm()" autocomplete="off" enctype="multipart/form-data">
<div class="ibox-head">
<div class="ibox-title"><i class="fas fa-user-tie" style="margin-right:10px;"></i>PATIENT ADMISSION FORM</div>
</div>
<div class="ibox-body">
<div class="row">
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>DATE OF ADMISSION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="date" name="date_of_admission" class="form-control form-control-air" value="<?php echo $date_of_admission; ?>" placeholder="Enter Name " required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>CENTER</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="center" class="form-control form-control-air" value=" Kegaon,Solapur" placeholder="" readonly required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>NAME OF PATIENT </b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-user"></i></span>
<input type="text" name="name_patient" class="form-control form-control-air" value="<?php echo $name_patient; ?>" placeholder="NAME OF PATIENT" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>GENDER</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><<i class="fas fa-venus-mars"></i></span>
<select name="gender"
class="form-control form-control-air">
<option value="male"<?php if($gender=="male"){?> selected <?php } ?>>MALE</option>
<option value="female"<?php if($gender=="female"){?> selected <?php } ?>>FEMALE</option>
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>ADDRESS </b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="address" class="form-control form-control-air" value="<?php echo $address; ?>" placeholder="ADDRESS" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>IS THIS RURUAL AREA</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<select name="is_rural"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<!-- <option value="yes">YES</option> -->
<option value="yes"<?php if($is_rural=="yes"){?> selected <?php } ?>>YES</option>
<option value="no"<?php if($is_rural=="no"){?> selected <?php } ?>>NO</option>
<!-- <option value="no">NO</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>CITY </b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="city" class="form-control form-control-air" value="<?php echo $city; ?>" placeholder="Enter City" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>STATE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="state" class="form-control form-control-air" value="<?php echo $state; ?>" placeholder="Enter STATE" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PIN</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-envelope"></i></span>
<input type="number" name="pin" class="form-control form-control-air" value="<?php echo $pin; ?>" placeholder="Enter PIN" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PHONE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-phone"></i></span>
<input type="number" name="phone" class="form-control form-control-air" value="<?php echo $phone; ?>" placeholder="Enter PHONE NO " required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>MOBILE NO</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-mobile-alt"></i></span>
<input type="number" name="mobile" class="form-control form-control-air" value="<?php echo $mobile; ?>" placeholder="Enter MOBILE NO " required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>EMAIL</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-envelope"></i></span>
<input type="email" name="email" class="form-control form-control-air" value="<?php echo $email; ?>" placeholder="Enter EMAIL " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>DATE OF BIRTH</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="date" name="date_of_birth" class="form-control form-control-air" value="<?php echo $date_of_birth; ?>" placeholder="Enter DATE OF BIRTH " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>AGE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="age" class="form-control form-control-air" value="<?php echo $age; ?>" placeholder="Enter AGE " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>RELIGION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="religion" class="form-control form-control-air" value="<?php echo $religion; ?>" placeholder="Enter RELIGION " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>EDUCATION QUALIFICATION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="education_qualification"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="ILLETRATE"<?php if($education_qualification=="ILLETRATE"){?> selected <?php } ?>>ILLETRATE</option>
<!-- <option value="ILLETRATE">ILLETRATE</option> -->
<option value="LITERATE"<?php if($education_qualification=="LITERATE"){?> selected <?php } ?>>LITERATE(READ & WRITE)</option>
<option value="LITERATE">LITERATE(READ & WRITE)</option>
<!-- <option value="PRIMARY">PRIMARY EDUCATION</option> -->
<option value="middle"<?php if($education_qualification=="middle"){?> selected <?php } ?>>MIDDLE</option>
<!-- <option value="middle">MIDDLE</option> -->
<option value="highersec"<?php if($education_qualification=="highersec"){?> selected <?php } ?>>HIGHER/HIGHER SECONDARY</option>
<!-- <option value="Select">HIGHER/HIGHER SECONDARY</option> -->
<option value="GRADUATE"<?php if($education_qualification=="GRADUATE"){?> selected <?php } ?>>GRADUATE</option>
<!-- <option value="GRADUATE">GRADUATE</option> -->
<option value="POST_GRADUATE"<?php if($education_qualification=="POST_GRADUATE"){?> selected <?php } ?>>POST GRADUATE</option>
<!-- <option value="POST_GRADUATE">POST GRADUATE</option> -->
<option value="TRAINING"<?php if($education_qualification=="TRAINING"){?> selected <?php } ?>>TRAINING(DIPLOMA)</option>
<!-- <option value="TRAINING">TRAINING(DIPLOMA)</option> -->
<option value="NOT_KNOWN"<?php if($education_qualification=="NOT_KNOWN"){?> selected <?php } ?>>NOT KNOWN</option>
<!-- <option value="NOT_KNOWN">NOT KNOWN</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>OCCUPTION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="occupation"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="CURRENTLY_UNEMPLOYED"<?php if($occupation=="CURRENTLY_UNEMPLOYED"){?> selected <?php } ?>>CURRENTLY UNEMPLOYED</option>
<!-- <option value="CURRENTLY_UNEMPLOYED">CURRENTLY UNEMPLOYED</option> -->
<option value="NEVER_EMPLOYED"<?php if($occupation=="NEVER_EMPLOYED"){?> selected <?php } ?>>NEVER EMPLOYED</option>
<!-- <option value="NEVER_EMPLOYED">NEVER EMPLOYED</option> -->
<option value="PART_TIME"<?php if($occupation=="PART_TIME"){?> selected <?php } ?>>PART TIME</option>
<!-- <option value="PART_TIME">PART TIME</option> -->
<option value="FULL_TIME"<?php if($occupation=="FULL_TIME"){?> selected <?php } ?>>FULL TIME</option>
<!-- <option value="FULL_TIME">FULL TIME</option> -->
<option value="SELF_EMPLOYMEN"<?php if($occupation=="SELF_EMPLOYMEN"){?> selected <?php } ?>>SELF EMPLOYMEN</option>
<!-- <option value="SELF_EMPLOYMEN">SELF EMPLOYMENT</option> -->
<option value="STUDENT"<?php if($occupation=="STUDENT"){?> selected <?php } ?>>STUDENT</option>
<!-- <option value="STUDENT">STUDENT</option> -->
<option value="HOUSEWIFE"<?php if($occupation=="HOUSEWIFE"){?> selected <?php } ?>>HOUSEWIFE</option>
<!-- <option value="HOUSEWIFE">HOUSEWIFE</option> -->
<option value="PENSIONER"<?php if($occupation=="PENSIONER"){?> selected <?php } ?>>PENSIONER</option>
<!-- <option value="PENSIONER">PENSIONER</option> -->
<option value="NOT_KNOWN"<?php if($occupation=="NOT_KNOWN"){?> selected <?php } ?>>NOT KNOWN</option>
<!-- <option value="NOT_KNOWN">NOT KNOWN</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>INCOME PER MONTH RS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="incone_per_month" class="form-control form-control-air" value="<?php echo $incone_per_month; ?>" placeholder="Enter INCOME PER MONTH RS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>FAMILY INCOME </b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="family" class="form-control form-control-air" value="<?php echo $family; ?>" placeholder="Enter FAMILY INCOME " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>MARITAL STATUS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="marital_status"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="NEVER_MARRIED"<?php if($marital_status=="NEVER_MARRIED"){?> selected <?php } ?>>NEVER MARRIED</option>
<!-- <option value="NEVER_MARRIED">NEVER MARRIED</option> -->
<option value="MARRIED"<?php if($marital_status=="MARRIED"){?> selected <?php } ?>>MARRIED</option>
<option value="MARRIED">MARRIED</option>
<option value="widow"<?php if($marital_status=="widow"){?> selected <?php } ?>>WIDOW / WIDOWER</option>
<!-- <option value="MARRIED">WIDOW / WIDOWER</option> -->
<option value="DIVORCED"<?php if($marital_status=="DIVORCED"){?> selected <?php } ?>>DIVORCED</option>
<!-- <option value="MARRIED">DIVORCED</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>LIVING ARRANGEMENTS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="living_arrangements"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="WITH_FAMILY"<?php if($living_arrangements=="WITH_FAMILY"){?> selected <?php } ?>>WITH FAMILY</option>
<!-- <option value="WITH_FAMILY">WITH FAMILY</option> -->
<option value="WITH_FRIEND"<?php if($living_arrangements=="WITH_FRIEND"){?> selected <?php } ?>>WITH FRIENDS OR RELATIVES</option>
<!-- <option value="WITH FRIENDS">WITH FRIENDS OR RELATIVES</option> -->
<option value="LIVING_ALONE"<?php if($living_arrangements=="LIVING_ALONE"){?> selected <?php } ?>>LIVING ALONE</option>
<!-- <option value="LIVING_ALONE">LIVING ALONE</option> -->
<option value="ON_STREET"<?php if($living_arrangements=="ON_STREET"){?> selected <?php } ?>>ON STREET</option>
<!-- <option value="ON_STREET">ON STREET</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<!-- <div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>TOATAL AMOUNT</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-money-check"></i></span>
<input type="number" name="totalamount" class="form-control form-control-air" value="<?php echo $totalamount; ?>" placeholder="Enter FAMILY INCOME " required/>
</div>
</div> -->
<BR>
<div class="ibox-head col-sm-12 col-md-12 col-lg-12 form-group mb-12">
<div class="ibox-title"><i class="fas fa-user-tie" style="margin-right:10px;"></i>NAME OF FAMILY MEMBER / SUPPORT PERSON ACCOMPANIED THE PATIENT</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b> MR./MRS. MS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="name_family_member" class="form-control form-control-air" value="<?php echo $name_family_member; ?>" placeholder="Enter NAME OF FAMILY MEMBERS" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>FAMILY MEMBER AGE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="realtive_age" class="form-control form-control-air" placeholder="Enter age OF FAMILY MEMBERS" required value="<?php echo $realtive_age; ?>"/>
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>ADDRESS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="address_family_mem" class="form-control form-control-air" value="<?php echo $address_family_mem; ?>" placeholder="Enter ADDRESS OF FAMILY MEMBER" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PHONE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-phone"></i> </span>
<input type="number" name="phone_family" class="form-control form-control-air" value="<?php echo $phone_family; ?>" placeholder="Enter PHONE NO " required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>MOBILE NO</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-mobile-alt"></i></span>
<input type="number" name="mobile_family" class="form-control form-control-air" value="<?php echo $mobile_family; ?>" placeholder="Enter MOBILE NO " required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>EMAIL</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-envelope"></i></span>
<input type="email" name="email_family" class="form-control form-control-air" value="<?php echo $email_family; ?>" placeholder="Enter EMAIL " />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>REFERRED BY</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="referred_by"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="SELF"<?php if($referred_by=="SELF"){?> selected <?php } ?>>SELF</option>
<!-- <option value="SELF">SELF</option> -->
<option value="RECOVERED_ADDICT"<?php if($referred_by=="RECOVERED_ADDICT"){?> selected <?php } ?>>RECOVERED ADDICT / FAMILY MEMBER</option>
<!-- <option value="RECOVERED_ADDICT">RECOVERED ADDICT / FAMILY MEMBER</option> -->
<option value="FRIENDS"<?php if($referred_by=="FRIENDS"){?> selected <?php } ?>>FRIENDS</option>
<!-- <option value="FRIENDS">FRIENDS</option> -->
<option value="GOVT_HOSPITAL"<?php if($referred_by=="GOVT_HOSPITAL"){?> selected <?php } ?>>GOVT HOSPITAL</option>
<!-- <option value="GOVT_HOSPITAL">GOVT HOSPITAL</option> -->
<option value="FAMILY"<?php if($referred_by=="FAMILY"){?> selected <?php } ?>>FAMILY</option>
<!-- <option value="FAMILY">FAMILY</option> -->
<option value="TREATENT_REHABILITATION_CENTER"<?php if($referred_by=="TREATENT_REHABILITATION_CENTER"){?> selected <?php } ?>>TREATENT REHABILITATION CENTER</option>
<!-- <option value="TREATENT_REHABILITATION_CENTER">TREATENT REHABILITATION CENTER</option> -->
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>REASON OF ADDICTION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i
class="fas fa-note"></i></span>
<select name="reason_of_addiction"
class="form-control form-control-air">
<!-- <option value="Select">Select</option> -->
<option value="CURIOSITY"<?php if($reason_of_addiction=="CURIOSITY"){?> selected <?php } ?>>CURIOSITY</option>
<!-- <option value="CURIOSITY">CURIOSITY</option> -->
<option value="FAMILY_PROBLEM"<?php if($reason_of_addiction=="FAMILY_PROBLEM"){?> selected <?php } ?>>FAMILY PROBLEM</option>
<!-- <option value="FAMILY_PROBLEM">FAMILY PROBLEM</option> -->
<option value="PEER_PRESSURE"<?php if($reason_of_addiction=="PEER_PRESSURE"){?> selected <?php } ?>>PEER PRESSURE</option>
<!-- <option value="PEER_PRESSURE">PEER PRESSURE</option> -->
<option value="GOVT_HOSPITAL"<?php if($reason_of_addiction=="GOVT_HOSPITAL"){?> selected <?php } ?>>GOVT HOSPITAL</option>
<!-- <option value="GOVT_HOSPITAL">GOVT HOSPITAL</option> -->
<option value="PERSONAL_PROBLEM"<?php if($reason_of_addiction=="PERSONAL_PROBLEM"){?> selected <?php } ?>>PERSONAL PROBLEM</option>
<!-- <option value="PERSONAL_PROBLEM">PERSONAL PROBLEM</option> -->
<option value="ANXIETY"<?php if($reason_of_addiction=="ANXIETY"){?> selected <?php } ?>>ANXIETY</option>
<!-- <option value="ANXIETY">ANXIETY</option> -->
<option value="DEPRESSION"<?php if($reason_of_addiction=="DEPRESSION"){?> selected <?php } ?>>DEPRESSION</option>
<!-- <option value="DEPRESSION">DEPRESSION</option> -->
<option value="FRUSTRATION"<?php if($reason_of_addiction=="FRUSTRATION"){?> selected <?php } ?>>FRUSTRATION</option>
<!-- <option value="FRUSTRATION">FRUSTRATION</option> -->
<option value="OTHER"<?php if($reason_of_addiction=="OTHER"){?> selected <?php } ?>>OTHER</option>
<option value="OTHER">OTHER</option>
</option>
</select>
<!-- <span style = "color:red"> <?php echo $var_user_type_error; ?></span> -->
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>TYPE OF ADDICTION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="type_addiction" class="form-control form-control-air" value="<?php echo $type_addiction; ?>" placeholder="Enter TYPE OF ADDICTION" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>YEAR OF ADDICTION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="year_of_addiction" class="form-control form-control-air" placeholder="Enter TYPE OF ADDICTION" value="<?php echo $year_of_addiction; ?>" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>JAUNDICE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="jaundice" class="form-control form-control-air" value="<?php echo $jaundice; ?>" placeholder="JAUNDICE" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>MALENA</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="malena" class="form-control form-control-air" value="<?php echo $malena; ?>" placeholder="MALENA" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>HEMELEMESIS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="hemelemesis" class="form-control form-control-air" value="<?php echo $malenamalena; ?>" placeholder="HEMELEMESIS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>CONVULSION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="convulsion" class="form-control form-control-air" value="<?php echo $convulsion; ?>" placeholder="CONVULSION" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>ASCITIS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="ascitis" class="form-control form-control-air" value="<?php echo $ascitis; ?>" placeholder="ASCITIS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>CHRONOC PEDAL OEDEMS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="chronic_pedal_oedems" class="form-control form-control-air" value="<?php echo $chronic_pedal_oedems; ?>" placeholder="CHRONOC PEDAL OEDEMS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PSYCHIATRIC PROBLEM</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="psychiatric_problem" class="form-control form-control-air" value="<?php echo $psychiatric_problem; ?>" placeholder="PSYCHIATRIC PROBLEM" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>HEART ATTACK</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="heart_attack" class="form-control form-control-air" value="<?php echo $heart_attack; ?>" placeholder="HEART ATTACK" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>SHOCK</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="shock" class="form-control form-control-air" value="<?php echo $shock; ?>" placeholder="SHOCK" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>TIA</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="tia" class="form-control form-control-air" value="<?php echo $tia; ?>" placeholder="TIA" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>KOCHS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="kochs" class="form-control form-control-air" value="<?php echo $kochs; ?>" placeholder="KOCHS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>HT</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="ht" class="form-control form-control-air" value="<?php echo $ht; ?>" placeholder="HT" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>DM</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="dm" class="form-control form-control-air" value="<?php echo $dm; ?>" placeholder="DM" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>AADHAR NUMBER</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="aadhar_no" class="form-control form-control-air" value="<?php echo $aadhar_no; ?>" placeholder="AADHAR NUMBER" />
</div>
</div>
<div class="ibox-head col-sm-12 col-md-12 col-lg-12 form-group mb-12">
<div class="ibox-title"><i class="fas fa-user-tie" style="margin-right:10px;"> COMPLAINTS</i></div>
</div>
<div class="past_history" style="display-flex; gap:50px; "!important></div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PRESENT COMPLAINTS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="present_coplaints" class="form-control form-control-air" value="<?php echo $present_coplaints ?>" placeholder="PRESENT COMPLAINTS" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>OTHER FINDINGS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="other_findings" class="form-control form-control-air" value="<?php echo $other_findings ?>" placeholder="OTHER FINDINGS" />
</div>
</div>
<script type="text/javascript">
const countries = {
"am-ET": "Amharic",
"ar-SA": "Arabic",
"be-BY": "Bielarus",
"bem-ZM": "Bemba",
"bi-VU": "Bislama",
"bjs-BB": "Bajan",
"bn-IN": "Bengali",
"bo-CN": "Tibetan",
"br-FR": "Breton",
"bs-BA": "Bosnian",
"ca-ES": "Catalan",
"cop-EG": "Coptic",
"cs-CZ": "Czech",
"cy-GB": "Welsh",
"da-DK": "Danish",
"dz-BT": "Dzongkha",
"de-DE": "German",
"dv-MV": "Maldivian",
"el-GR": "Greek",
"en-GB": "English",
"es-ES": "Spanish",
"et-EE": "Estonian",
"eu-ES": "Basque",
"fa-IR": "Persian",
"fi-FI": "Finnish",
"fn-FNG": "Fanagalo",
"fo-FO": "Faroese",
"fr-FR": "French",
"gl-ES": "Galician",
"gu-IN": "Gujarati",
"ha-NE": "Hausa",
"he-IL": "Hebrew",
"hi-IN": "Hindi",
"hr-HR": "Croatian",
"hu-HU": "Hungarian",
"id-ID": "Indonesian",
"is-IS": "Icelandic",
"it-IT": "Italian",
"ja-JP": "Japanese",
"kk-KZ": "Kazakh",
"km-KM": "Khmer",
"kn-IN": "Kannada",
"ko-KR": "Korean",
"ku-TR": "Kurdish",
"ky-KG": "Kyrgyz",
"la-VA": "Latin",
"lo-LA": "Lao",
"lv-LV": "Latvian",
"men-SL": "Mende",
"mg-MG": "Malagasy",
"mi-NZ": "Maori",
"ms-MY": "Malay",
"mt-MT": "Maltese",
"my-MM": "Burmese",
"ne-NP": "Nepali",
"niu-NU": "Niuean",
"nl-NL": "Dutch",
"no-NO": "Norwegian",
"ny-MW": "Nyanja",
"ur-PK": "Pakistani",
"pau-PW": "Palauan",
"pa-IN": "Panjabi",
"ps-PK": "Pashto",
"pis-SB": "Pijin",
"pl-PL": "Polish",
"pt-PT": "Portuguese",
"rn-BI": "Kirundi",
"ro-RO": "Romanian",
"ru-RU": "Russian",
"sg-CF": "Sango",
"si-LK": "Sinhala",
"sk-SK": "Slovak",
"sm-WS": "Samoan",
"sn-ZW": "Shona",
"so-SO": "Somali",
"sq-AL": "Albanian",
"sr-RS": "Serbian",
"sv-SE": "Swedish",
"sw-SZ": "Swahili",
"ta-LK": "Tamil",
"te-IN": "Telugu",
"tet-TL": "Tetum",
"tg-TJ": "Tajik",
"th-TH": "Thai",
"ti-TI": "Tigrinya",
"tk-TM": "Turkmen",
"tl-PH": "Tagalog",
"tn-BW": "Tswana",
"to-TO": "Tongan",
"tr-TR": "Turkish",
"uk-UA": "Ukrainian",
"uz-UZ": "Uzbek",
"vi-VN": "Vietnamese",
"wo-SN": "Wolof",
"xh-ZA": "Xhosa",
"yi-YD": "Yiddish",
"zu-ZA": "Zulu"
}
</script>
<div class="ibox-head col-sm-12 col-md-12 col-lg-12 form-group mb-12">
<div class="ibox-title"><i class="fas fa-user-tie" style="margin-right:10px;"> प्रतिज्ञापत्र</i></div>
</div>
<!-- <div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>NAME</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="pratidnya_name" class="form-control form-control-air" value="<?php echo $pratidnya_name; ?>" placeholder="ENTER NAME" required />
</div>
</div> -->
<style type="text/css">
textarea{
height: 40px;
width: 100px;
margin-top: 20px;
}
.translatebtn
{
height: 40px;
width: 100px;
margin-top: 20px;
}
.exchange i {
visibility: hidden;
}
.select{
visibility: hidden;
}
</style>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>RELATIVE NAME (मराठी)</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" class="to-text form-control form-control-air" name="pratidnya_name" placeholder="RELATIVE NAME" value="<?php echo $pratidnya_name ?>" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>PATIENT NAME (मराठी)</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" class="to-text form-control form-control-air" name="patient_marathi" placeholder="Patinet Name" value="<?php echo $patient_marathi ?>" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>RELATION</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="relation" class="form-control form-control-air" value="<?php echo $relation; ?>" placeholder="ENTER Relation" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>ADDRESS</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="pratidnya_address" class="form-control form-control-air" value="<?php echo $pratidnya_address; ?>" placeholder="ENTER ADDRESS" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>MOBILE NUMBER</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-mobile-alt"></i></span>
<input type="number" name="pratidnya_mobile" class="form-control form-control-air" value="<?php echo $pratidnya_mobile; ?>" placeholder="ENTER MOBILE NUMBER" required />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>AGE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="number" name="pratidnya_age" class="form-control form-control-air" value="<?php echo $pratidnya_age; ?>" placeholder="ENTER AGE" required />
</div>
</div>
<div class="ibox-head col-sm-12 col-md-12 col-lg-12 form-group mb-12">
<div class="ibox-title"><i class="fas fa-user-tie" style="margin-right:10px;"> DISCHARGE DETAILS</i></div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>DOCTOR NAME</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="text" name="dcotor_name" class="form-control form-control-air" value="<?php echo $dcotor_name; ?>" placeholder="ENTER NAME" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>DISCHARGE DATE</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-building"></i></span>
<input type="DATE" name="discharge_date" class="form-control form-control-air" value="<?php echo $discharge_date; ?>" placeholder="ENTER DATE" />
</div>
</div>
<div class="col-sm-2 col-md-2 col-lg-2 form-group mb-2">
<label class="form-group mb-4 set-row label_marg"><b>समुपदेशक नाव</b></label>
<div class="input-group-icon input-group-icon-left set-row">
<span class="input-icon input-icon-left"><i class="fas fa-map-marker-alt"></i></span>
<input type="text" name="samupdeshk_name" class="form-control form-control-air" value="<?php echo $samupdeshk_name; ?>" placeholder="ENTER NAME" />
</div>
</div>
<div class="col-sm-12 form-group mb-12" style="text-align:center; padding-left:0px; padding-right:0px; padding-top:20px;">
<div class="col-sm-4 form-group mb-4" style="margin:auto;">
<button class="btn btn-pink btn-air" type="submit" name="add" style="width:100%;">SAVE DETAILS</button>
</div>
</div>
</div>
<!-- <center><a href="staff-form-report.php" style="color:red;font-weight:bold;">Back To List</a></center> -->
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<?php //include('search.php'); ?>
<div class="sidenav-backdrop backdrop"></div>
<div class="preloader-backdrop">
<div class="page-preloader">Loading</div>
</div>
<script src="js/jquery.min.js"></script>
<script src="js/popper.min.js"></script>
<script src="js/bootstrap.min.js"></script>
<script src="js/metisMenu.min.js"></script>
<script src="js/jquery.slimscroll.min.js"></script>
<script src="js/idle-timer.min.js"></script>
<script src="js/toastr.min.js"></script>
<script src="js/jquery.validate.min.js"></script>
<script src="js/bootstrap-select.min.js"></script>
<script src="datatable/datatables.min.js"></script>
<script src="js/app.min.js"></script>
</body>
</html>
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