-
Notifications
You must be signed in to change notification settings - Fork 0
/
Orthopedic_Form.html
239 lines (224 loc) · 11.3 KB
/
Orthopedic_Form.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Orthopedic Patient Information Form</title>
<!-- Bootstrap CSS -->
<link href="https://maxcdn.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css" rel="stylesheet">
<link href="Orthopedic_Form.css" rel="stylesheet">
<script src="Orthopedic_Form.js"></script>
</head>
<body>
<div class="container mt-5">
<h2>Orthopedic Patient Information Form</h2>
<input id="Autofill_Button" class="btn btn-primary" type="button" value="Autofill" onclick="Autofill()">
<form>
<!-- Personal Information -->
<div class="form-group">
<label for="name">Name:</label>
<input type="text" class="form-control" id="name" placeholder="Enter name">
</div>
<div class="form-group">
<label for="age">Age:</label>
<input type="text" class="form-control" id="age" placeholder="Enter age">
</div>
<div class="form-group">
<label for="dob">Date of Birth:</label>
<input type="date" class="form-control" id="dob">
</div>
<div class="form-group">
<label>Gender:</label>
<div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="male" value="Male">
<label class="form-check-label" for="male">Male</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="female" value="Female">
<label class="form-check-label" for="female">Female</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="other" value="Other">
<label class="form-check-label" for="other">Other</label>
</div>
</div>
</div>
<div class="form-group">
<label for="bloodGroup">Blood Group:</label>
<select class="form-control" id="bloodGroup">
<option value="1">A+</option>
<option value="2">A-</option>
<option value="3">B+</option>
<option value="4">B-</option>
<option value="5">O+</option>
<option value="6">O-</option>
<option value="7">AB+</option>
<option value="8">AB-</option>
</select>
</div>
<div class="form-group">
<label for="height">Height (cm):</label>
<input type="text" class="form-control" id="height" placeholder="Enter height">
</div>
<div class="form-group">
<label for="weight">Weight (kg):</label>
<input type="text" class="form-control" id="weight" placeholder="Enter weight">
</div>
<div class="form-group">
<label for="diagnosis">Diagnosis:</label>
<input type="text" class="form-control" id="diagnosis" placeholder="Enter diagnosis">
</div>
<div class="form-group">
<label for="followUpDate">Follow-up Date:</label>
<input type="date" class="form-control" id="followUpDate">
</div>
<div class="form-group">
<label for="operationDate">Operation Date:</label>
<input type="date" class="form-control" id="operationDate">
</div>
<div class="form-group">
<label>Medical History:</label>
<div class="form-check">
<input type="checkbox" class="form-check-input" id="previousFractures">
<label class="form-check-label" for="previousFractures">Previous history of fractures</label>
</div>
<div class="form-check">
<input type="checkbox" class="form-check-input" id="familyHistory">
<label class="form-check-label" for="familyHistory">Family history of bone disorders</label>
</div>
<div class="form-group">
<label for="otherMedicalHistory">Other:</label>
<input type="text" class="form-control" id="otherMedicalHistory" placeholder="Enter other medical history">
</div>
</div>
<div class="form-group">
<label for="additionalComments">Additional Comments:</label>
<textarea class="form-control" id="additionalComments" rows="3"></textarea>
</div>
<!-- Hospital Information -->
<h3>Hospital Information</h3>
<div class="form-group">
<label for="hospitalName">Hospital Name:</label>
<input type="text" class="form-control" id="hospitalName" placeholder="Enter hospital name">
</div>
<div class="form-group">
<label for="hospitalAddress">Hospital Address:</label>
<textarea class="form-control" id="hospitalAddress" rows="3"
placeholder="Enter hospital address"></textarea>
</div>
<div class="form-group">
<label for="doctorName">Doctor Name:</label>
<input type="text" class="form-control" id="doctorName" placeholder="Enter doctor's name">
</div>
<div class="form-group">
<label for="doctorSpecialization">Doctor Specialization:</label>
<input type="text" class="form-control" id="doctorSpecialization"
placeholder="Enter doctor's specialization">
</div>
<!-- Medication Plan -->
<h3>Medication Plan</h3>
<div class="form-group">
<label for="medicationName1">Medication Name:</label>
<input type="text" class="form-control" id="medicationName1" placeholder="Enter medication name">
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="dosage1">Dosage (mg):</label>
<input type="text" class="form-control" id="dosage1" placeholder="Enter dosage">
</div>
<div class="form-group col-md-4">
<label for="frequency1">Frequency:</label>
<input type="text" class="form-control" id="frequency1" placeholder="Enter frequency">
</div>
<div class="form-group col-md-4">
<label for="startDate1">Start Date:</label>
<input type="date" class="form-control" id="startDate1">
</div>
<div class="form-group col-md-4">
<label for="endDate1">End Date:</label>
<input type="date" class="form-control" id="endDate1">
</div>
</div>
<div class="form-group">
<label for="medicationName2">Medication Name:</label>
<input type="text" class="form-control" id="medicationName2" placeholder="Enter medication name">
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="dosage2">Dosage (mg):</label>
<input type="text" class="form-control" id="dosage2" placeholder="Enter dosage">
</div>
<div class="form-group col-md-4">
<label for="frequency2">Frequency:</label>
<input type="text" class="form-control" id="frequency2" placeholder="Enter frequency">
</div>
<div class="form-group col-md-4">
<label for="startDate2">Start Date:</label>
<input type="date" class="form-control" id="startDate2">
</div>
<div class="form-group col-md-4">
<label for="endDate2">End Date:</label>
<input type="date" class="form-control" id="endDate2">
</div>
</div>
<!-- Physical Therapy Plan -->
<h3>Physical Therapy Plan</h3>
<div class="form-group">
<label for="sessionFrequency">Session Frequency:</label>
<input type="text" class="form-control" id="sessionFrequency" placeholder="e.g., Twice a week">
</div>
<div class="form-group">
<label for="therapyStartDate">Start Date:</label>
<input type="date" class="form-control" id="therapyStartDate">
</div>
<div class="form-group">
<label for="therapyEndDate">End Date:</label>
<input type="date" class="form-control" id="therapyEndDate">
</div>
<!-- Imaging -->
<h3>Imaging</h3>
<div class="form-group">
<label for="Imaging Technique">Imaging Technique:</label>
<input type="text" class="form-control" id="xray" placeholder="for e.g., X-ray">
<!-- readonly -->
</div>
<!-- Orthopedic Assessment -->
<h3>Orthopedic Assessment</h3>
<div class="form-group">
<label for="fractureType">Fracture Type:</label>
<input type="text" class="form-control" id="fractureType" placeholder="Enter fracture type">
</div>
<div class="form-group">
<label for="fractureLocation">Fracture Location:</label>
<input type="text" class="form-control" id="fractureLocation" placeholder="Enter fracture location">
</div>
<div class="form-group">
<label for="stability">Stability:</label>
<input type="text" class="form-control" id="stability" placeholder="Enter stability">
</div>
<!-- Functional Assessment -->
<h3>Functional Assessment</h3>
<div class="form-group">
<label for="mobility">Mobility:</label>
<input type="text" class="form-control" id="mobility" placeholder="Enter mobility assessment">
</div>
<div class="form-group">
<label for="adls">Activities of Daily Living (ADLs):</label>
<input type="text" class="form-control" id="adls" placeholder="Enter ADLs assessment">
</div>
<button type="submit" class="btn btn-primary">Submit</button>
</form>
</div>
<!-- <script>
function Autofill() {
console.log("Clicked");
document.getElementById("Autofill_Button").innerHTML = "The form will be filled automatically..!!";
}
</script> -->
<!-- Bootstrap JS and Popper.js -->
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.16.0/umd/popper.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/4.5.2/js/bootstrap.min.js"></script>
</body>
</html>