391 lines
26 KiB
PHP
Executable File
391 lines
26 KiB
PHP
Executable File
<div class="content-body">
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<div class="row">
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<div class="col-12">
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<div class="card">
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<!--sidebar end-->
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<!--main content start-->
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<section id="main-content">
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<section class="wrapper site-min-height">
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<!-- page start-->
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<section class="row col-md-10">
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<div class="card-header">
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<h3 class="font-weight-bold"> <?php
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if (!empty($nurse->id))
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echo lang('Edit Patient');
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else
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echo lang('Edit referral Patient');
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?></h3>
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</div>
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<!-- <div class="panel-body col-md-7">
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<div class="adv-table editable-table ">
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<div class="clearfix">
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<div class="col-lg-12">
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<section class="panel">
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<div class="panel-body">
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<div class="col-lg-12">
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</div>
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<input type="hidden" name="id" value='<?php
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if (!empty($nurse->id)) {
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echo $nurse->id;
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}
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?>'>
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<button type="submit" name="submit" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</form>
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</div>
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</section>
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</div>
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</div>
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</div>
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</div> -->
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<div class="panel-body col-md-12">
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<div class="col-lg-3"></div>
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<div class="col-lg-6">
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<?php echo validation_errors(); ?>
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<?php echo $this->session->flashdata('feedback'); ?>
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</div>
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<div class="col-lg-3"></div>
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<div class="col-md-12">
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<div class="wizard wizard-circle">
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<div class="steps">
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<ul class="nav nav-tabs" id="myTab" role="tablist" style="border: none;">
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<li class="nav-item first current">
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<a class="nav-link " id="home-tab" data-toggle="tab" href="#home" role="tab" aria-selected="true" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">1</span>General Information</a>
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</li>
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<li class="nav-item first current" >
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<a class="nav-link" id="profile-tab" data-toggle="tab" href="#designate" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">2</span>Designate</a>
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</li>
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<li class="nav-item first current">
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<a class="nav-link" id="contact-tab" data-toggle="tab" href="#service_need" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">3</span>Service & Referral</a>
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</li>
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</ul>
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</div>
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</div>
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<!-- <ul class="nav nav-tabs" id="myTab" role="tablist">
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<li class="nav-item active">
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<a class="nav-link " id="home-tab" data-toggle="tab" href="#home" role="tab" aria-controls="home" aria-selected="true">General Information</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" id="profile-tab" data-toggle="tab" href="#designate" role="tab" aria-controls="profile" aria-selected="false">Designate</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" id="contact-tab" data-toggle="tab" href="#service_need" role="tab" aria-controls="contact" aria-selected="false">Service & Referral</a>
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</li>
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</ul> -->
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<!-- basic_info tab -->
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<div class="tab-content" id="myTabContent">
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<div class="tab-pane fade active in show" id="home" role="tabpanel" aria-labelledby="home-tab">
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<form role="form" action="patient/EditReferralPatientChanges?pid=<?=$_GET['pid']?>" method="post" enctype="multipart/form-data">
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('First name'); ?></label>
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<input type="text" class="form-control" name="fname"
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value="<?php echo $pdata->first_name; ?>">
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<!-- value='<?php
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if (!empty($setval)) {
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echo set_value('name');
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}
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if (!empty($nurse->name)) {
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echo $nurse->name;
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}
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?>'> -->
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Last name'); ?></label>
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<input type="text" class="form-control" name="lname"
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value=<?php echo $pdata->last_name; ?>>
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</div>
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</div>
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</div>
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<div class="form-group">
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<label for="exampleInputEmail1"><?php echo lang('email'); ?></label>
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<input type="text" class="form-control" name="email" id="exampleInputEmail1" value=<?php echo $pdata->patient_email; ?> placeholder="">
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Gender'); ?></label>
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<select class="form-control" name="gender" id="inputGroupSelect01" name="pnalguage">
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<option selected>Choose...</option>
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<option <?php echo ($pdata->gender == 'Male')?'selected':'' ; ?> value="Male">Male</option>
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<option <?php echo ($pdata->gender == 'Female')?'selected':'' ; ?> value="Female">Female</option>
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<option <?php echo ($pdata->gender == 'Others')?'selected':'' ; ?> value="Others">Others</option>
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</select>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Primary language'); ?></label>
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<select class="form-control" id="inputGroupSelect01" name="pnalguage">
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<option selected>Choose...</option>
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<option <?php echo ($pdata->primary_language == 'English')?'selected':'' ; ?> value="English">English</option>
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<option <?php echo ($pdata->primary_language == 'Hindi')?'selected':'' ; ?> value="Hindi">Hindi</option>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1"><?php echo lang('Date of Birth'); ?></label>
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<input type="date" class="form-control" id="ptdob" name="dob" value=<?php echo $pdata->dob; ?>>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1"><?php echo lang('Telephone'); ?></label>
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<input type="text" class="form-control" name="telephone" value='<?php echo $pdata->telephone; ?>'>
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</div>
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</div>
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</div>
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<div class="col-md-12 form-group">
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<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</div>
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</form>
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</div>
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<!-- designate tab -->
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<div class="tab-pane fade" id="designate" role="tabpanel" aria-labelledby="profile-tab">
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<form role="form" action="patient/EditReferralPatientChanges?pid=<?=$_GET['pid']?>" method="post" enctype="multipart/form-data">
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('First name'); ?></label>
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<input type="text" class="form-control" name="dg_fname" value='<?php echo $pdata->designate_first_name; ?>'>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Last name'); ?></label>
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<input type="text" class="form-control" name="dg_lname" value='<?php echo $pdata->designate_last_name; ?>'>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Telephone'); ?></label>
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<input type="text" class="form-control" name="dg_telephone" value='<?php echo $pdata->designate_telephone; ?>'>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Cell'); ?></label>
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<input type="text" class="form-control" name="dg_cell" value='<?php echo $pdata->designate_cell; ?>'>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Email'); ?></label>
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<input type="text" class="form-control" name="dsg_email" value='<?php echo $pdata->designate_email; ?>'>
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</div>
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</div>
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</div>
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<div class="col-md-12 form-group">
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<button type="submit" name="submit" value="ref_designate" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</div>
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</form>
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</div>
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<div class="tab-pane fade" id="service_need" role="tabpanel" aria-labelledby="contact-tab">
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<form role="form" action="patient/EditReferralPatientChanges?pid=<?=$_GET['pid']?>" method="post" enctype="multipart/form-data">
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<div class="form-group">
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<div class="row">
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<div class="col-lg-12">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Level of care needed'); ?></label>
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<select class="form-control" name="level_care" id="inputGroupSelect01">
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<option value="" selected>Choose...</option>
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<option value="1">1 high</option>
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<option value="2">2</option>
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<option value="3">3</option>
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<option value="4">4</option>
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<option value="5">5 low</option>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Referal source'); ?></label>
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<select class="form-control" name="referal_source" id="inputGroupSelect01">
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<option value="" selected>Choose...</option>
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<?php foreach ($preferal as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Referal Recive Date'); ?></label>
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<input type="date" class="form-control" name="referal_recive_date" id="exampleInputEmail1" >
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal contact'); ?></label>
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<select class="form-control" name="referal_name" id="inputGroupSelect01">
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<option value="" selected>Choose...</option>
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<option value="Name">Name</option>
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<option value="Address">Address</option>
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<option value="Email">Email</option>
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<option value="Fax">Fax</option>
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<option value="Phone">Phone</option>
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</select>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal Type'); ?></label>
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<select class="form-control" name="referal_type" id="inputGroupSelect01">
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<option value="" selected>Choose...</option>
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<option value="New">New</option>
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<option value="Restart">Restart</option>
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</select>
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</div>
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<!-- <div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal Address'); ?></label>
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<input type="text" class="form-control" name="referal_address" id="exampleInputEmail1">
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</div> -->
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</div>
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</div>
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<!-- <div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal email'); ?></label>
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<input type="text" class="form-control" name="referal_email" id="exampleInputEmail1">
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal Phone'); ?></label>
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<input type="text" class="form-control" name="referal_phone" id="exampleInputEmail1">
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</div>
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</div>
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</div> -->
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Level of Service needed'); ?></label>
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<select class="form-control" name="level_service" id="inputGroupSelect01">
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<option selected>Choose...</option>
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<?php foreach ($lvlService as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Service Activity Needed'); ?></label>
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<select class="form-control" name="service_activity" id="inputGroupSelect01" multiple>
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<option value="" selected>Choose...</option>
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<?php foreach ($serviceActivity as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Therapy Type'); ?></label>
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<select class="form-control" name="therapy_type" id="inputGroupSelect01" multiple>
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<option value="" selected>Choose...</option>
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<?php foreach ($therapyType as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Type of access'); ?></label>
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<select class="form-control" name="type_access" id="inputGroupSelect01" multiple>
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<option value="" selected>Choose...</option>
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<?php foreach ($accessType as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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</div>
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<div class="col-md-12 form-group">
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<button type="submit" name="submit" value="referal_src" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</div>
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</form>
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</div>
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</div>
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</div>
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</div>
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</section>
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<!-- page end-->
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</section>
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</section>
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</div>
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</div>
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</div>
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</div>
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<!-- <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
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<?php if(isset($_GET['pid']) && !isset($_GET['phase2'])): ?>
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<script type="text/javascript">
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$(function(){
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$('#myTab li:nth-child(2) a').tab('show');
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})
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</script>
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<?php endif; ?>
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<?php if( isset($_GET['pid']) && isset($_GET['phase2']) ): ?>
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<script type="text/javascript">
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$(function(){
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$('#myTab li:nth-child(3) a').tab('show');
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})
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</script>
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<?php endif; ?> -->
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<!--main content end-->
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<!--footer start-->
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