1400 lines
65 KiB
PHP
Executable File
1400 lines
65 KiB
PHP
Executable File
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/ProfileUpdate" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation caregiverPhyTabForm" onsubmit="return basic_phy_Validation();">
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
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<input type="hidden" name="form_tab_status" value="5">
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<input type="hidden" id="PhyTabVerificStatus" value="<?php echo $nurse->verification_status?>">
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
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<input type="hidden" name="form_status" value="5">
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<input type="hidden" name="form_mode" value="<?php if($nurse->form_status>0) echo 'Edit'; else echo 'Add'; ?>">
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<?php
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$short_code=[];
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$status=[];
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$object = new stdClass();
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$empHealthArr = $nurse->emp_health_assessment;
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foreach ($empHealthArr as $key => $value) {
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array_push($short_code,$value->short_code);
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array_push($status,$value->status);
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}
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$tuberculosisArr = $nurse->emp_tuberculosis_data;
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foreach ($tuberculosisArr as $key => $value) {
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array_push($short_code,$value->short_code);
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array_push($status,$value->status);
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}
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// _die($short_code);
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$new_health_array=array_combine($short_code,$status);
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$drugScreenJson = json_decode($nurse->drug_screen);
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$physcialAssesmentJson = json_decode($nurse->physical_assesment);
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$under_care_physicianJson = json_decode($nurse->under_care_physician);
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// _die($physcialAssesmentJson);
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foreach($new_health_array as $key=>$val){
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$object->$key=$val;
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}
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foreach($drugScreenJson as $key=>$val){
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$object->$key=$val;
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}
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foreach($under_care_physicianJson as $key=>$val){
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$object->$key=$val;
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}
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foreach($physcialAssesmentJson as $key=>$val){
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$object->$key=$val;
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}
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$emp_health_assesment = $object;
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// _die($emp_health_assesment);
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?>
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<div class="row">
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<div class="col-md-12">
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<h5 class="text-center font-weight-bold">Health Assessment</h5>
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</div>
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<div class="col-md-12 center">
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<label class="" style="text-align: center;">
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Indicate if you are suffering from or have a history of the following conditions:
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</label>
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</div>
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<div class="col-md-12 center">
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<label class="text-danger" style="text-align: center;">
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***If you answer “YES” to any question under this section then an Employment Clearance letter from your physician must be uploaded***
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</label>
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</div>
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<div class="col-md-6 phyQrs">
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<table width="100%">
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<tr>
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<th>Condition</th>
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<th>Yes</th>
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<th>No</th>
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</tr>
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<tr>
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<td>Diabetes</td>
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<td>
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<input type="radio" name="diabetes" id="radio1" value="1" <?php if ($emp_health_assesment->diabetes==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="diabetes" id="radio1" value="0" <?php if ($emp_health_assesment->diabetes==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Kidney Disease</td>
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<td>
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<input type="radio" name="kidney_disease" id="radio1" value="1" <?php if ($emp_health_assesment->kidney_disease==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="kidney_disease" id="radio1" value="0" <?php if ($emp_health_assesment->kidney_disease==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Heart Disease</td>
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<td>
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<input type="radio" name="heart_disease" id="radio1" value="1" <?php if ($emp_health_assesment->heart_disease==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="heart_disease" id="radio1" value="0" <?php if ($emp_health_assesment->heart_disease==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>High Blood Pressure</td>
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<td>
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<input type="radio" name="high_blood_pressure" id="radio1" value="1" <?php if ($emp_health_assesment->high_blood_pressure==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="high_blood_pressure" id="radio1" value="0" <?php if ($emp_health_assesment->high_blood_pressure==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Arthritis</td>
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<td>
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<input type="radio" name="arthritis" id="radio1" value="1" <?php if ($emp_health_assesment->arthritis==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="arthritis" id="radio1" value="0" <?php if ($emp_health_assesment->arthritis==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Mental Illness</td>
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<td>
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<input type="radio" name="mental_illness" id="radio1" value="1" <?php if ($emp_health_assesment->mental_illness==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="mental_illness" id="radio1" value="0" <?php if ($emp_health_assesment->mental_illness==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Seizure/Convulsion</td>
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<td>
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<input type="radio" name="epilepsy" id="radio1" value="1" <?php if ($emp_health_assesment->epilepsy==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="epilepsy" id="radio1" value="0" <?php if ($emp_health_assesment->epilepsy==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Swelling in the Extremities</td>
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<td>
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<input type="radio" name="swelling_extremities" id="radio1" value="1" <?php if ($emp_health_assesment->swelling_extremities==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="swelling_extremities" id="radio1" value="0" <?php if ($emp_health_assesment->swelling_extremities==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Allergies</td>
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<td>
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<input type="radio" name="allergies" id="radio1" value="1" <?php if ($emp_health_assesment->allergies==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="allergies" id="radio1" value="0" <?php if ($emp_health_assesment->allergies==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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</table>
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</div>
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<div class="col-md-6 phyQrs">
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<table width="100%">
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<tr>
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<th>Condition</th>
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<th>Yes</th>
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<th>No</th>
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</tr>
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<tr>
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<td>Back Pain</td>
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<td>
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<input type="radio" name="back_pain" id="radio1" value="1" <?php if ($emp_health_assesment->back_pain==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="back_pain" id="radio1" value="0" <?php if ($emp_health_assesment->back_pain==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Pain on Urination</td>
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<td>
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<input type="radio" name="pain_urination" id="radio1" value="1" <?php if ($emp_health_assesment->pain_urination==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="pain_urination" id="radio1" value="0" <?php if ($emp_health_assesment->pain_urination==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Change in Bowel Habits</td>
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<td>
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<input type="radio" name="change_bowel_habit" id="radio1" value="1" <?php if ($emp_health_assesment->change_bowel_habit==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="change_bowel_habit" id="radio1" value="0" <?php if ($emp_health_assesment->change_bowel_habit==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Increased Thrust</td>
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<td>
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<input type="radio" name="increased_thirst" id="radio1" value="1" <?php if ($emp_health_assesment->increased_thirst==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="increased_thirst" id="radio1" value="0" <?php if ($emp_health_assesment->increased_thirst==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Persistent Sores/Lumps</td>
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<td>
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<input type="radio" name="persistent_lumps" id="radio1" value="1" <?php if ($emp_health_assesment->persistent_lumps==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="persistent_lumps" id="radio1" value="0" <?php if ($emp_health_assesment->persistent_lumps==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Infectious Disease</td>
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<td>
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<input type="radio" name="infectious_disease" id="radio1" value="1" <?php if ($emp_health_assesment->infectious_disease==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="infectious_disease" id="radio1" value="0" <?php if ($emp_health_assesment->infectious_disease==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Cancer</td>
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<td>
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<input type="radio" name="cancer" id="radio1" value="1" <?php if ($emp_health_assesment->cancer==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="cancer" id="radio1" value="0" <?php if ($emp_health_assesment->cancer==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Any Other Physical Disability</td>
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<td>
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<input type="radio" name="other_disability" id="radio1" value="1" <?php if ($emp_health_assesment->other_disability==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="other_disability" id="radio1" value="0" <?php if ($emp_health_assesment->other_disability==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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</table>
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</div>
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</div>
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<hr>
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<div class="row">
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<!-- TURBERCULOSIS QUESTIONNAIRE -->
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<div class="col-md-12">
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<h5 class="text-center font-weight-bold">Tuberculosis Questionnaire</h5>
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</div>
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<label class="col-md-12" style="text-align: center;">
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Indicate if you have been experiencing the following conditions:
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</label>
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<div class="col-md-6 phyQrs">
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<table width="100%">
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<tr>
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<th>Condition</th>
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<th>Yes</th>
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<th>No</th>
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</tr>
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<tr>
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<td>Persistent Cough for < 3 Weeks</td>
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<td>
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<input type="radio" name="cough_3_weeks" id="radio1" value="1" <?php if ($emp_health_assesment->cough_3_weeks==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="cough_3_weeks" id="radio1" value="0" <?php if ($emp_health_assesment->cough_3_weeks==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Blood in the Sputum</td>
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<td>
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<input type="radio" name="blood_sputum" id="radio1" value="1" <?php if ($emp_health_assesment->blood_sputum==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="blood_sputum" id="radio1" value="0" <?php if ($emp_health_assesment->blood_sputum==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Shortness of Breath</td>
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<td>
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<input type="radio" name="shortness_breath" id="radio1" value="1" <?php if ($emp_health_assesment->shortness_breath==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="shortness_breath" id="radio1" value="0" <?php if ($emp_health_assesment->shortness_breath==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Night Sweats</td>
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<td>
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<input type="radio" name="night_sweat" id="radio1" value="1" <?php if ($emp_health_assesment->night_sweat==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="night_sweat" id="radio1" value="0" <?php if ($emp_health_assesment->night_sweat==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Chest Pain</td>
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<td>
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<input type="radio" name="chest_pain" id="radio1" value="1" <?php if ($emp_health_assesment->chest_pain==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="chest_pain" id="radio1" value="0" <?php if ($emp_health_assesment->chest_pain==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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</table>
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</div>
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<div class="col-md-6 phyQrs" >
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<table width="100%">
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<tr>
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<th>Condition</th>
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<th>Yes</th>
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<th>No</th>
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</tr>
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<tr>
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<td>Unexplained Weight Loss</td>
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<td>
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<input type="radio" name="unexplained_weight_loss" id="radio1" value="1" <?php if ($emp_health_assesment->unexplained_weight_loss==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="unexplained_weight_loss" id="radio1" value="0" <?php if ($emp_health_assesment->unexplained_weight_loss==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Loss of Appetite</td>
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<td>
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<input type="radio" name="appetite_loss" id="radio1" value="1" <?php if ($emp_health_assesment->appetite_loss==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="appetite_loss" id="radio1" value="0" <?php if ($emp_health_assesment->appetite_loss==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Hoarseness</td>
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<td>
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<input type="radio" name="hoarseness" id="radio1" value="1" <?php if ($emp_health_assesment->hoarseness==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="hoarseness" id="radio1" value="0" <?php if ($emp_health_assesment->hoarseness==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Increased Thirst</td>
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<td>
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<input type="radio" name="thirst_increase" id="radio1" value="1" <?php if ($emp_health_assesment->thirst_increase==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="thirst_increase" id="radio1" value="0" <?php if ($emp_health_assesment->thirst_increase==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Fatigue</td>
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<td>
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<input type="radio" name="fatigue" id="radio1" value="1" <?php if ($emp_health_assesment->fatigue==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="fatigue" id="radio1" value="0" <?php if ($emp_health_assesment->fatigue==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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<tr>
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<td>Fever</td>
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<td>
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<input type="radio" name="fever" id="radio1" value="1" <?php if ($emp_health_assesment->fever==1) {
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echo "checked"; } ?>/>
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</td>
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<td>
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<input type="radio" name="fever" id="radio1" value="0" <?php if ($emp_health_assesment->fever==0) {
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echo "checked"; } ?>/>
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</td>
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</tr>
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</table>
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</div>
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</div>
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<!-- <div class="row">
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1" class="required-field"><?php echo lang('Have you had a positive PPD reading?'); ?></label>
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<div class="col-md-6">
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<div class="row">
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<div class="form-check width-80">
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<input class="form-check-input" type="radio" id="positive_ppdYES" name="positive_ppd" value="1" <?php if ($emp_health_assesment->positive_ppd==1) {
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echo "checked"; } ?>>
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<label class="form-check-label" for="positive_ppdYES">Yes
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|
</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" id="positive_ppdNO" name="positive_ppd" value="0" <?php if ($emp_health_assesment->positive_ppd==0) {
|
|
echo "checked"; } ?>>
|
|
<label class="form-check-label" for="positive_ppdNO">No
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 ppdExplain" <?php if ($emp_health_assesment->positive_ppd ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="ppd_explain" value='<?php
|
|
if (!empty($setval)) {
|
|
echo set_value('ppd_explain');
|
|
}
|
|
if (!empty($emp_health_assesment->ppd_explain)) {
|
|
echo $emp_health_assesment->ppd_explain;
|
|
}
|
|
?>' placeholder="">
|
|
</div>
|
|
</div> -->
|
|
<script>
|
|
$('input[name=positive_ppd]').on('change', function() {
|
|
var value = $(this).val();
|
|
if(value > 0){
|
|
$(".ppdExplain").show();
|
|
}else{
|
|
$(".ppdExplain").hide();
|
|
}
|
|
});
|
|
</script>
|
|
<div class="row">
|
|
<div class="col-md-12">
|
|
<label>
|
|
<b><?php //echo lang('Tuberculosis Questionnaire'); ?></b><br>
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Have you received Hepatatis vaccine?');?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" name="hepatatis_vaccine" id="hepatatis_vaccine_yes" value="1"
|
|
<?php if (isset($nurse->hepatatis_vaccine) && $nurse->hepatatis_vaccine==1){echo "checked"; } ?>/>
|
|
<label class="form-check-label" for="hepatatis_vaccine_yes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" name="hepatatis_vaccine" id="hepatatis_vaccine_no" value="0"
|
|
<?php if (isset($nurse->hepatatis_vaccine) && $nurse->hepatatis_vaccine==0){echo "checked"; } ?>/>
|
|
<label class="form-check-label" for="hepatatis_vaccine_no">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Have you had a positive PPD reading?'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" name="positive_ppd" id="positive_ppd_yes" value="1"
|
|
<?php if (isset($nurse->positive_ppd) && $nurse->positive_ppd==1){echo "checked"; } ?>/>
|
|
<label class="form-check-label" for="positive_ppd_yes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" name="positive_ppd" id="positive_ppd_no" value="0"
|
|
<?php if (isset($nurse->positive_ppd) && $nurse->positive_ppd==0){echo "checked"; } ?>/>
|
|
<label class="form-check-label" for="positive_ppd_no">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<!-- <div class="form-group col-md-6 under_care_explain" <?php if ($emp_health_assesment->under_care ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="under_care_explain" value='<?php
|
|
if (!empty($setval)) {
|
|
echo set_value('under_care_explain');
|
|
}
|
|
if (!empty($emp_health_assesment->under_care_explain)) {
|
|
echo $emp_health_assesment->under_care_explain;
|
|
}
|
|
?>' placeholder="">
|
|
</div> -->
|
|
</div>
|
|
|
|
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-12">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Are you under the care of a physician?'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" id="under_careYES" name="under_care" value="1"
|
|
<?php if($emp_health_assesment->under_care==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="under_careYES">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" id="under_careNO" name="under_care" value="0"
|
|
<?php if($emp_health_assesment->under_care==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="under_careNO">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<?php $under_care_hide="";if($emp_health_assesment->under_care==0){$under_care_hide="style='display:none'";} ?>
|
|
<div class="form-group col-md-4 under_care_explain" <?=$under_care_hide?>>
|
|
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="under_care_explain" id="under_care_explain"
|
|
value='<?php
|
|
if (!empty($setval)){echo set_value('under_care_explain');}
|
|
if(!empty($emp_health_assesment->under_care_explain)){echo $emp_health_assesment->under_care_explain;}
|
|
?>'
|
|
placeholder="">
|
|
<div id=under_care_explainError style="display: none;color: #B94A48;" >Field can't be blank</div>
|
|
</div>
|
|
<div class="form-group col-md-4 under-care-phy-name" <?=$under_care_hide?>>
|
|
<label for="exampleInputEmail1"><?php echo lang('Name of Your Primary Care Physician'); ?></label>
|
|
<input type="text" class="form-control" name="name_of_physician" id="name_of_physician"
|
|
value='<?php
|
|
if(!empty($setval)){echo set_value('name_of_physician');}
|
|
if (!empty($emp_health_assesment->name_of_physician)){echo $emp_health_assesment->name_of_physician;}
|
|
?>'
|
|
placeholder="">
|
|
<div id=name_of_physicianError style="display: none;color: #B94A48;" >Field can't be blank</div>
|
|
</div>
|
|
<div class="form-group col-md-4 under-care-phy-telephone" <?=$under_care_hide?>>
|
|
<label for="exampleInputEmail1"><?php echo lang('Telephone of Your Primary Care Physician'); ?></label>
|
|
<input type="text" class="form-control" name="tel_of_physician" id="tel_of_physician" onkeypress="return isNumberKey(event)" onkeyup="USformatPhoneNumber(this.value,this)"
|
|
onblur="USformatPhoneNumber(this.value,this)"
|
|
value='<?php
|
|
if(!empty($setval)){echo set_value('tel_of_physician');}
|
|
if (!empty($emp_health_assesment->tel_of_physician)){echo $emp_health_assesment->tel_of_physician;}
|
|
?>'
|
|
placeholder="">
|
|
<div id=tel_of_physicianError style="display: none;color: #B94A48;" >Field can't be blank</div>
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$('input[name=under_care]').on('change', function() {
|
|
var value=$(this).val();
|
|
if(value>0){
|
|
$(".under_care_explain").show();
|
|
$(".under-care-phy-name").show();
|
|
$(".under-care-phy-telephone").show();
|
|
}else{
|
|
$(".under_care_explain").hide();
|
|
$(".under-care-phy-name").hide();
|
|
$(".under-care-phy-telephone").hide();
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<hr>
|
|
<div class="row">
|
|
<div class="col-md-12">
|
|
<label>
|
|
<b><?php echo lang('Drug Screen Attestation'); ?></b> 
|
|
</label>
|
|
<label class="text-danger drug-screen-file-notice" style="text-align: center;">
|
|
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field">
|
|
<?php echo lang('Do you take depressants, stimulants, and/or narcotic drugs that alter your behavior?'); ?>
|
|
</label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input behaviour-test-radio" type="radio" id="change_behaviourYES" name="change_behaviour" value="1"
|
|
<?php if ($emp_health_assesment->change_behaviour==1){echo "checked";}?>>
|
|
<label class="form-check-label" for="change_behaviourYES">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input behaviour-test-radio" type="radio" id="change_behaviourNO" name="change_behaviour" value="0"
|
|
<?php if ($emp_health_assesment->change_behaviour==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="change_behaviourNO">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 change_behaviour_explain" <?php if($emp_health_assesment->change_behaviour ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="change_behaviour_explain"
|
|
value='<?php if(!empty($setval)){echo set_value('change_behaviour_explain');}
|
|
if(!empty($emp_health_assesment->change_behaviour_explain)){echo $emp_health_assesment->change_behaviour_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var behaviour_value=$('.behaviour-test-radio:checked').val();
|
|
behaviour_test_reason(behaviour_value);
|
|
$('input[name=change_behaviour]').on('change', function() {
|
|
var behaviour_value=$(this).val();
|
|
behaviour_test_reason(behaviour_value);
|
|
});
|
|
function behaviour_test_reason(value){
|
|
var target=$(".change_behaviour_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
$(".drug-screen-file-notice").text("");
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
$(".drug-screen-file-notice").text("(***Since you answered “YES” an Employment Clearance letter from your physician must be uploaded***)");
|
|
|
|
}
|
|
}
|
|
});
|
|
// $('input[name=change_behaviour]').on('change', function() {
|
|
// var value = $(this).val();
|
|
// if(value > 0){
|
|
// $(".change_behaviour_explain").show();
|
|
// }else{
|
|
// $(".change_behaviour_explain").hide();
|
|
// }
|
|
// });
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="col-md-12">
|
|
<label>
|
|
<b><?php echo lang('Physical Assessment'); ?></b><br>
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field">
|
|
<?php echo lang('Do you take prescription medications? '); ?>
|
|
</label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input medications-test-radio" type="radio" id="prescription_medicationsYES" name="prescription_medications" value="1"
|
|
<?php if ($emp_phy_data->prescription_medications==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="prescription_medicationsYES">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input medications-test-radio" type="radio" id="prescription_medicationsNO" name="prescription_medications" value="0"
|
|
<?php if ($emp_phy_data->prescription_medications==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="prescription_medicationsNO">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 prescription_medications_explain"
|
|
<?php if ($emp_phy_data->prescription_medications ==0 ) {?> style="display:none" <?php }?>>
|
|
<label for="exampleInputEmail1"><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="prescription_medications_explain"
|
|
value='<?php if (!empty($setval)){echo set_value('prescription_medications_explain');}
|
|
if (!empty($emp_phy_data->prescription_medications_explain)){echo $emp_phy_data->prescription_medications_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var medications_value=$('.medications-test-radio:checked').val();
|
|
medications_test_reason(medications_value);
|
|
$('input[name=prescription_medications]').on('change', function() {
|
|
var medications_value=$(this).val();
|
|
medications_test_reason(medications_value);
|
|
});
|
|
function medications_test_reason(value){
|
|
var target=$(".prescription_medications_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
// $('input[name=prescription_medications]').on('change', function() {
|
|
// var value = $(this).val();
|
|
// if(value > 0){
|
|
// $(".prescription_medications_explain").show();
|
|
// }else{
|
|
// $(".prescription_medications_explain").hide();
|
|
// }
|
|
// });
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field">
|
|
<?php echo lang('If required in your position, would you be willing to have screening test for drugs done on your blood /urine as a condition for employment? '); ?>
|
|
</label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input screening-test-radio" type="radio" id="screening_testYES" name="screening_test" value="1"
|
|
<?php if($emp_phy_data->screening_test=="1" || $emp_phy_data->screening_test==""){echo "checked";}?>>
|
|
<label class="form-check-label" for="screening_testYES">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input screening-test-radio" type="radio" id="screening_testNO" name="screening_test" value="0"
|
|
<?php if($emp_phy_data->screening_test=="0"){echo "checked";}?>>
|
|
<label class="form-check-label" for="screening_testNO">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 screening_test_explain" <?php if ($emp_phy_data->screening_test !=0 ) {?> style="display:none" <?php } ?>>
|
|
<label for="exampleInputEmail1"><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="screening_test_explain" value='<?php
|
|
if (!empty($setval)) {
|
|
echo set_value('screening_test_explain');
|
|
}
|
|
if (!empty($emp_phy_data->screening_test_explain)) {
|
|
echo $emp_phy_data->screening_test_explain;
|
|
}
|
|
?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var screening_value=$('.screening-test-radio:checked').val();
|
|
screening_test_reason(screening_value);
|
|
$('input[name=screening_test]').on('change', function() {
|
|
var screening_value=$(this).val();
|
|
screening_test_reason(screening_value);
|
|
});
|
|
function screening_test_reason(value){
|
|
var target=$(".screening_test_explain");
|
|
if(value>0){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field">
|
|
<?php echo lang('Have you had any operations or hospitalization for illnesses past 5 years?'); ?>
|
|
</label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input illness-test-radio" type="radio" id="past_illnessYES" name="past_illness" value="1"
|
|
<?php if ($emp_phy_data->past_illness==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="past_illnessYES">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input illness-test-radio" type="radio" id="past_illnessNO" name="past_illness" value="0"
|
|
<?php if ($emp_phy_data->past_illness==0) {echo "checked"; } ?>>
|
|
<label class="form-check-label" for="past_illnessNO">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 past_illness_explain" <?php if ($emp_phy_data->past_illness ==0 ){?> style="display:none" <?php }?>>
|
|
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="past_illness_explain"
|
|
value='<?php if (!empty($setval)){echo set_value('past_illness_explain');}
|
|
if(!empty($emp_phy_data->past_illness_explain)){echo $emp_phy_data->past_illness_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var illness_value=$('.illness-test-radio:checked').val();
|
|
illness_test_reason(illness_value);
|
|
$('input[name=past_illness]').on('change', function(){
|
|
var illness_value=$(this).val();
|
|
illness_test_reason(illness_value);
|
|
});
|
|
function illness_test_reason(value){
|
|
var target=$(".past_illness_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
// $('input[name=past_illness]').on('change', function() {
|
|
// var value = $(this).val();
|
|
// if(value > 0){
|
|
// $(".past_illness_explain").show();
|
|
// }else{
|
|
// $(".past_illness_explain").hide();
|
|
// }
|
|
// });
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label class="required-field">
|
|
<?php echo lang('Do you have any physical defects that preclude you from performing any work for which you are being hired? '); ?>
|
|
</label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input physicaldefects physicaldefects-test-radio" type="radio" id="physicaldefectsyes" name="physicaldefects" value="1"
|
|
<?php if ($emp_phy_data->physicaldefects==1){ echo "checked"; } ?>>
|
|
<label class="form-check-label" for="physicaldefectsyes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input physicaldefects physicaldefects-test-radio" type="radio" id="physicaldefectsno" name="physicaldefects" value="0"
|
|
<?php if ($emp_phy_data->physicaldefects==0) { echo "checked"; } ?>>
|
|
<label class="form-check-label" for="physicaldefectsno">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 physicaldefects_explain" id="physicaldefectsDetails" <?php if ($emp_phy_data->physicaldefects ==0 ){?> style="display:none" <?php } ?>>
|
|
<label ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="physicaldefects_explain"
|
|
value='<?php if (!empty($setval)){echo set_value('physicaldefects_details');}
|
|
if(!empty($emp_phy_data->physicaldefects_explain)){echo $emp_phy_data->physicaldefects_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var physicaldefects_value=$('.physicaldefects-test-radio:checked').val();
|
|
physicaldefects_test_reason(physicaldefects_value);
|
|
$('input[name=physicaldefects]').on('change', function(){
|
|
var physicaldefects_value=$(this).val();
|
|
physicaldefects_test_reason(physicaldefects_value);
|
|
});
|
|
function physicaldefects_test_reason(value){
|
|
var target=$(".physicaldefects_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label class="required-field"><?php echo lang('Were you ever injured?'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input injury injured-test-radio" type="radio" id="injuredyes" name="injured" value="1" <?php if ($emp_phy_data->injured==1) {echo "checked"; }?>>
|
|
<label class="form-check-label" for="injuredyes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input injury injured-test-radio" type="radio" id="injuredno" name="injured" value="0" <?php if ($emp_phy_data->injured==0) { echo "checked"; } ?>>
|
|
<label class="form-check-label" for="injuredno">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 injured_explain" id="injuryDetails" <?php if ($emp_phy_data->injured ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="injured_explain" id="injuryDetailsField"
|
|
value='<?php if (!empty($setval)){echo set_value('injured_explain');}
|
|
if(!empty($emp_phy_data->injured_explain)){echo $emp_phy_data->injured_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var injured_value=$('.injured-test-radio:checked').val();
|
|
injured_test_reason(injured_value);
|
|
$('input[name=injured]').on('change', function(){
|
|
var injured_value=$(this).val();
|
|
injured_test_reason(injured_value);
|
|
});
|
|
function injured_test_reason(value){
|
|
var target=$(".injured_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label class="required-field"><?php echo lang('Do you have any defects in hearing?');?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input hearingdefects defects-test-radio" type="radio" id="defectsyes" name="defects" value="1"
|
|
<?php if ($emp_phy_data->defects==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="defectsyes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input hearingdefects defects-test-radio" type="radio" id="defectsno" name="defects" value="0"
|
|
<?php if ($emp_phy_data->defects==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="defectsno">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 defects_explain" id="hearingdefectsDetails" <?php if ($emp_phy_data->defects ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="defects_explain" id="hearingdefectsDetailsField"
|
|
value='<?php if (!empty($setval)){echo set_value('defects_explain');}
|
|
if(!empty($emp_phy_data->defects_explain)){echo $emp_phy_data->defects_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var defects_value=$('.defects-test-radio:checked').val();
|
|
defects_test_reason(defects_value);
|
|
$('input[name=defects]').on('change', function(){
|
|
var defects_value=$(this).val();
|
|
defects_test_reason(defects_value);
|
|
});
|
|
function defects_test_reason(value){
|
|
var target=$(".defects_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label class="required-field"><?php echo lang('In vision'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input visiondefects invision-test-radio" type="radio" id="inVisionyes" name="inVision" value="1"
|
|
<?php if ($emp_phy_data->inVision==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="inVisionyes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input visiondefects invision-test-radio" type="radio" id="inVisionno" name="inVision" value="0"
|
|
<?php if ($emp_phy_data->inVision==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="inVisionno">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 invision_explain" id="visiondefectsDetails" <?php if ($emp_phy_data->inVision ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="inVision_explain" id="visiondefectsDetailsField"
|
|
value='<?php if (!empty($setval)){echo set_value('inVision_explain');}
|
|
if(!empty($emp_phy_data->inVision_explain)){echo $emp_phy_data->inVision_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var invision_value=$('.invision-test-radio:checked').val();
|
|
invision_test_reason(invision_value);
|
|
$('input[name=inVision]').on('change', function(){
|
|
var invision_value=$(this).val();
|
|
invision_test_reason(invision_value);
|
|
});
|
|
function invision_test_reason(value){
|
|
var target=$(".invision_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label class="required-field"><?php echo lang('In speech'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input speechdefects speach-test-radio" type="radio" id="speachyes" name="speach" value="1"
|
|
<?php if ($emp_phy_data->speach==1){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="speachyes">Yes</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input speechdefects speach-test-radio" type="radio" id="speachno" name="speach" value="0"
|
|
<?php if($emp_phy_data->speach==0){echo "checked"; } ?>>
|
|
<label class="form-check-label" for="speachno">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6 speach_explain" id="speechdefectsDetails" <?php if ($emp_phy_data->speach ==0 ) {?> style="display:none" <?php } ?>>
|
|
<label ><?php echo lang('Explain'); ?></label>
|
|
<input type="text" class="form-control" name="speach_explain" id="speechdefectsDetailsField"
|
|
value='<?php if (!empty($setval)){echo set_value('speach_explain');}
|
|
if(!empty($emp_phy_data->speach_explain)){echo $emp_phy_data->speach_explain;}?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
<script>
|
|
$(document).ready(function(){
|
|
var speach_value=$('.speach-test-radio:checked').val();
|
|
speach_test_reason(speach_value);
|
|
$('input[name=speach]').on('change', function(){
|
|
var speach_value=$(this).val();
|
|
speach_test_reason(speach_value);
|
|
});
|
|
function speach_test_reason(value){
|
|
var target=$(".speach_explain");
|
|
if(value!=1){
|
|
target.hide();
|
|
target.children("label").removeClass("required-field");
|
|
target.children("input").prop("required",false);
|
|
target.children("input").removeAttr('value');
|
|
}else{
|
|
target.show();
|
|
target.children("label").addClass("required-field");
|
|
target.children("input").prop("required",true);
|
|
}
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<div class="row">
|
|
<!-- <div class="form-group col-md-6">
|
|
<label class="required-field"><?php echo lang('Have you had a Covid-19 test within the last month?'); ?></label>
|
|
<div class="col-md-6">
|
|
<div class="row">
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" id="covidtestYes" name="covidtest" value="1" <?php if ($emp_health_assesment->covidtest==1) {
|
|
echo "checked"; } ?>>
|
|
<label class="form-check-label" for="covidtestYes">Yes
|
|
</label>
|
|
</div>
|
|
<div class="form-check width-80">
|
|
<input class="form-check-input" type="radio" id="covidtestNo" name="covidtest" value="0" <?php if ($emp_health_assesment->covidtest==0) {
|
|
echo "checked"; } ?>>
|
|
<label class="form-check-label" for="covidtestNo">No
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div> -->
|
|
</div>
|
|
|
|
<!-- <div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Name of Your Primary Care Physician'); ?></label>
|
|
<input type="text" class="form-control" name="name_of_physician"
|
|
value='<?php
|
|
if(!empty($setval)){echo set_value('name_of_physician');}
|
|
if (!empty($emp_health_assesment->name_of_physician)){echo $emp_health_assesment->name_of_physician;}
|
|
?>'
|
|
placeholder="">
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Telephone'); ?></label>
|
|
<input type="text" class="form-control" name="tel_of_physician" onkeypress="return isNumberKey(event)" onkeyup="USformatPhoneNumber(this.value,this)"
|
|
onblur="USformatPhoneNumber(this.value,this)"
|
|
value='<?php
|
|
if(!empty($setval)){echo set_value('tel_of_physician');}
|
|
if (!empty($emp_health_assesment->tel_of_physician)){echo $emp_health_assesment->tel_of_physician;}
|
|
?>'
|
|
placeholder="">
|
|
</div>
|
|
</div> -->
|
|
|
|
<hr>
|
|
<div class="row">
|
|
<div class="form-group col-md-3">
|
|
<label class="required-field"><?php echo lang('Eye Color'); ?></label>
|
|
<select class="form-control" name="eye_color" required data-error="Please Select Eye Color.">
|
|
<option value="" selected disabled>Select</option>
|
|
<?php foreach ($eyeColors as $eyeColor) { ?>
|
|
<option value="<?php echo $eyeColor->name; ?>" <?php
|
|
if (!empty($setval)) {
|
|
if ($eyeColor->name == set_value('eye_color')) {
|
|
echo 'selected';
|
|
}
|
|
}
|
|
if (!empty($nurse->eye_color)) {
|
|
if ($nurse->eye_color == $eyeColor->name) {
|
|
echo 'selected';
|
|
}
|
|
}
|
|
?> > <?php echo $eyeColor->name; ?> </option>
|
|
<?php } ?>
|
|
</select>
|
|
<div class="help-block with-errors"></div>
|
|
</div>
|
|
<div class="form-group col-md-3">
|
|
<label class="required-field"><?php echo lang('Hair Color'); ?></label>
|
|
<select class="form-control" name="hair_color" required data-error="Please Select Hair Color">
|
|
<option value="" selected disabled>Select</option>
|
|
<?php foreach ($hairColors as $hairColor) { ?>
|
|
<option value="<?php echo $hairColor->name; ?>" <?php
|
|
if (!empty($setval)) {
|
|
if ($hairColor->name == set_value('hair_color')) {
|
|
echo 'selected';
|
|
}
|
|
}
|
|
if (!empty($nurse->hair_color)) {
|
|
if ($nurse->hair_color == $hairColor->name) {
|
|
echo 'selected';
|
|
}
|
|
}
|
|
?> > <?php echo $hairColor->name; ?> </option>
|
|
<?php } ?>
|
|
</select>
|
|
<div class="help-block with-errors"></div>
|
|
</div>
|
|
<?php $physical_exam_form=json_decode($nurse->physical_exam_form); ?>
|
|
<div class="form-group col-md-3">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Height (feet & inches)'); ?></label>
|
|
<div class="input-group">
|
|
<input type="number" class="form-control height-feet-phy-tab" name="height_feet" id="height_feet" min="1" value="<?php echo $physical_exam_form->height_feet; ?>" required/>
|
|
<span class=""> & </span>
|
|
<input type="number" class="form-control height-inch-phy-tab" name="height_inches" id="height_inches" min="0" value="<?php echo $physical_exam_form->height_inches; ?>" required>
|
|
|
|
</div>
|
|
<div class="help-block with-errors"></div>
|
|
<div class="txt-red" id="height_Error" style="color:red;font-size: 12.5px !important;"></div>
|
|
</div>
|
|
<div class="form-group col-md-3">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Weight in pounds (lbs)'); ?></label>
|
|
<div class="input-group">
|
|
<input type="number" class="form-control" name="weight" id="weight" min="1" value="<?php if($physical_exam_form->weight){echo $physical_exam_form->weight;}else{echo "1";} ?>" min="1" required>
|
|
|
|
</div> <div class="txt-red" id="weight_Error" style="color:red;font-size: 12.5px !important;"></div>
|
|
</div>
|
|
</div>
|
|
<!-- <div class="row">
|
|
<div class="form-group col-md-12">
|
|
<label class="inner-heading">Traveling Information</label>
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label ><?php echo lang('Will You Drive to Work?'); ?></label>
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<select class="form-control" name="drive_info" id="drive_info" onchange="ShowHideAutomobileInfo();">
|
|
<option value="" Select Disabled>Select</option>
|
|
<option value="No" <?php if ($nurse->drive_info=="No"){ echo "Selected"; } ?>>No</option>
|
|
<option value="Yes" <?php if ($nurse->drive_info=="Yes"){ echo "Selected"; } ?> >Yes</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="row" id="automobile_insurance_info" <?php if($nurse->drive_info!="Yes"){ echo "Style='Display:none;'"; } ?>>
|
|
<div class="form-group col-md-4">
|
|
<label class="required-field"><?php echo lang('Automobile Policy Holder Name'); ?></label>
|
|
<input type="text" class="form-control" name="Automobile_Policy_Holder_Name" value='<?php
|
|
if (!empty($nurse->Automobile_Policy_Holder_Name)) {
|
|
echo $nurse->Automobile_Policy_Holder_Name;
|
|
}
|
|
?>'>
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label class="required-field"><?php echo lang('Automobile Policy Number'); ?></label>
|
|
<input type="text" class="form-control" name="Automobile_Policy_Number" value='<?php
|
|
if (!empty($nurse->Automobile_Policy_Number)) {
|
|
echo $nurse->Automobile_Policy_Number;
|
|
}
|
|
?>'>
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label class="required-field"><?php echo lang('Automobile Policy Expiration Date'); ?></label>
|
|
<input type="date" class="form-control" name="Automobile_Policy_Expiration_Date" value='<?php
|
|
if (!empty($nurse->Automobile_Policy_Expiration_Date)) {
|
|
echo $nurse->Automobile_Policy_Expiration_Date;
|
|
}
|
|
?>'>
|
|
</div>
|
|
</div> -->
|
|
<!-- <div class="row">
|
|
<div class="form-group col-md-12">
|
|
<label class="inner-heading">Caregiver Preferences</label>
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<label ><?php echo lang('Preffered Gender'); ?></label>
|
|
<select class="form-control" name="Preffered_Gender">
|
|
<option value="" disable selected>Select</option>
|
|
<option value="Any" <?php if($nurse->Preffered_Gender=='Any') echo 'selected'; ?>>Any</option>
|
|
<option value="Male" <?php if($nurse->Preffered_Gender=='Male') echo 'selected'; ?>>Male</option>
|
|
<option value="Female" <?php if($nurse->Preffered_Gender=='Female') echo 'selected'; ?>>Female</option>
|
|
<option value="Other" <?php if($nurse->Preffered_Gender=='Other') echo 'selected'; ?>>Other</option>
|
|
</select>
|
|
<div class="help-block with-errors"></div>
|
|
</div>
|
|
<div class=" form-group col-md-6">
|
|
<label ><?php echo lang('Notes'); ?></label>
|
|
<input type="text" class="form-control" name="Notes" value='<?php
|
|
if (!empty($nurse->Notes)) {
|
|
echo $nurse->Notes;
|
|
}
|
|
?>'>
|
|
</div>
|
|
</div> -->
|
|
<hr>
|
|
<div class="form-group col-md-12 row mt-1">
|
|
<button type="submit" name="submit" id="PhyTab_submit_btn" onclick="return validatePhyTabForm()" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</div>
|
|
</form>
|
|
|
|
<script>
|
|
function validatePhyTabForm()
|
|
{
|
|
var check_under_care=false;
|
|
|
|
if($("#under_careYES").is(':checked')){
|
|
check_under_care=true;
|
|
}
|
|
if(check_under_care==true){
|
|
var under_care_explain = $('#under_care_explain').val();
|
|
var name_of_physician = $('#name_of_physician').val();
|
|
var tel_of_physician = $('#tel_of_physician').val();
|
|
// alert(malpractice_explanation);
|
|
if($.trim(under_care_explain) == ''){
|
|
// alert('hi');
|
|
$("#under_care_explainError").show();
|
|
return false;
|
|
}else{
|
|
$("#under_care_explainError").hide();
|
|
// return true;
|
|
}
|
|
|
|
if($.trim(name_of_physician) == ''){
|
|
// alert('hi');
|
|
$("#name_of_physicianError").show();
|
|
return false;
|
|
}else{
|
|
$("#name_of_physicianError").hide();
|
|
// return true;
|
|
}
|
|
|
|
if($.trim(tel_of_physician) == ''){
|
|
// alert('hi');
|
|
$("#tel_of_physicianError").show();
|
|
return false;
|
|
}else{
|
|
$("#tel_of_physicianError").hide();
|
|
// return true;
|
|
}
|
|
|
|
|
|
}
|
|
$("#height_Error").html('');
|
|
$("#weight_Error").html('');
|
|
var height_feet = $('#height_feet').val();
|
|
var height_inches = $('#height_inches').val();
|
|
var weight = $('#weight').val();
|
|
if($.trim(height_feet)!=''){
|
|
// if(height_feet.length>1){
|
|
// $("#height_Error").html('Please enter a valid height.');
|
|
// $('#height_feet').focus();
|
|
// return false;
|
|
// }
|
|
|
|
if(height_feet<2 || height_feet>9){
|
|
$("#height_Error").html('Please enter height between 2 ft to 9 ft.');
|
|
$('#height_feet').focus();
|
|
return false;
|
|
}
|
|
|
|
}
|
|
|
|
if($.trim(height_inches)!=''){
|
|
// if(height_inches.length>2){
|
|
// $("#height_Error").html('Please enter a valid height.');
|
|
// $('#height_inches').focus();
|
|
// return false;
|
|
// }
|
|
if(height_inches<0 || height_inches>12){
|
|
$("#height_Error").html('Please enter height inches between 0 inch to 12 inches.');
|
|
$('#height_feet').focus();
|
|
return false;
|
|
}
|
|
|
|
|
|
}
|
|
|
|
if($.trim(weight)!=''){
|
|
if(weight.length>3){
|
|
$("#weight_Error").html('Please enter a valid weight.');
|
|
$('#weight').focus();
|
|
return false;
|
|
}
|
|
|
|
if(weight<45 || weight>400){
|
|
$("#weight_Error").html('Please enter weight between 45lbs to 400lbs.');
|
|
$('#weight').focus();
|
|
return false;
|
|
}
|
|
|
|
}
|
|
|
|
return true;
|
|
}
|
|
function basic_phy_Validation(){
|
|
// if (confirm('Do you want to save the data'))
|
|
// {
|
|
// // Save it!
|
|
// return true;
|
|
// }
|
|
// else {
|
|
// // Do nothing!
|
|
// return false;
|
|
// }
|
|
}
|
|
|
|
// $( window ).on( "load", function() {
|
|
// var caregiverView = $('#PhyTabVerificStatus').val();
|
|
// if(caregiverView == 'verified'){
|
|
// $(".caregiverPhyTabForm :input").prop("disabled", true);
|
|
// $("#PhyTab_submit_btn").hide();
|
|
// }else{
|
|
// $(".caregiverPhyTabForm :input").prop("disabled", false);
|
|
// $("#PhyTab_submit_btn").show();
|
|
// }
|
|
// });
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
$(document).on('change','.height-feet-phy-tab',function(){
|
|
var inch=$(".height-inch-phy-tab").val();
|
|
// alert(inch);
|
|
if(inch==""){
|
|
$(this).siblings().val("0");
|
|
}
|
|
});
|
|
</script>
|