-
Notifications
You must be signed in to change notification settings - Fork 0
/
Copy pathpatient-blood_form.php
151 lines (131 loc) · 5.44 KB
/
patient-blood_form.php
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
<?php
include ("connection.php");
?>
<html>
<head><title> </title>
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css" integrity="sha384-JcKb8q3iqJ61gNV9KGb8thSsNjpSL0n8PARn9HuZOnIxN0hoP+VmmDGMN5t9UJ0Z" crossorigin="anonymous">
<link rel="stylesheet" href="css/patient-blood_form.css">
</head>
<body>
<ul class="nav">
<li class="nav-item">
<a class="nav-link active" href="main.html">Home</a>
</li>
<li class="nav-item">
<a class="nav-link" href="blood_info.html">In need of blood?</a>
</li>
<li class="nav-item">
<a class="nav-link" href="organ_info.html">In need of organs?</a>
</li>
<li class="nav-item">
<div class="dropdown">
<a class="btn btn-danger dropdown-toggle" href="#" id="dropdownMenuLink" data-toggle="dropdown" aria-haspopup="true" aria-expanded="false">
Become a donor
</a>
<div class="dropdown-menu" aria-labelledby="dropdownMenuLink">
<a class="dropdown-item" href="b_donor.html">Blood Donor</a>
<a class="dropdown-item" href="o_donor.html">Organ Donor</a>
</div>
</div>
</li>
</ul>
<div class="container">
<h3>Fill up the form and we will contact you soon!</h3>
<br>
<form action="" method="POST">
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">Full name</label>
<input type="text" class="form-control" id="validationDefault01" name="fullname" required>
</div>
</div>
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">Weight</label>
<input type="text" class="form-control" id="validationDefault01" placeholder="in kgs" name="weight" required>
</div>
<div class="col-md-6 mb-3">
<label for="validationDefault02" class="lists">Height</label>
<input type="text" class="form-control" id="validationDefault02" placeholder="in cms" name="height" required>
</div>
</div>
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">Age</label>
<input type="text" class="form-control" id="validationDefault01" name="age" required>
</div>
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">Phone no.</label>
<input type="text" class="form-control" id="validationDefault01" name="phone" required>
</div>
</div>
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">Blood Group</label>
<input type="text" class="form-control" id="validationDefault01" placeholder="Eg: A+" name="bloodgroup" required>
</div>
</div>
<div class="form-group">
<label for="exampleFormControlSelect1" class="lists">Gender</label>
<select class="form-control" id="exampleFormControlSelect1" name="genderSelect">
<option>Male</option>
<option>Female</option>
<option>Other</option>
</select>
</div>
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">State</label>
<input type="text" class="form-control" id="validationDefault01" name="state" required>
</div>
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists">City</label>
<input type="text" class="form-control" id="validationDefault01" name="city" required>
</div>
</div>
<div class="form-row">
<div class="col-md-6 mb-3">
<label for="validationDefault01" class="lists"> Registration Date</label>
<input type="text" class="form-control" id="validationDefault01" placeholder="YYYY-MM-DD" name="date" required>
</div>
</div>
<br>
<h5>Note: Kindly check all the details carefully before submitting.</h5>
<button type="submit" class="btn btn-danger">Submit</button>
</form>
<?php
if($_SERVER['REQUEST_METHOD'] == 'POST'){
$fullname=$_POST['fullname'];
$weight=$_POST['weight'];
$height=$_POST['height'];
$age=$_POST['age'];
$phone=$_POST['phone'];
$bloodgrp=$_POST['bloodgroup'];
$genderSelect=$_POST['genderSelect'];
$state=$_POST['state'];
$city=$_POST['city'];
$date=$_POST['date'];
// && $lname!="" && $age!="" && $weight!="" && $height="" && $bloodgrp!=""
//&& $state!="" && $town!="" && $pincode!="" && $phone!="" && $genderSelect!=""
//&& $month!="" && $day!="" && $year!=""
//echo 'hello';
$query="INSERT INTO blood_patient(fullname,weight,height,age,pno,bloodgrp,gender,state,city,date) values('$fullname','$weight','$height','$age','$phone',
'$bloodgrp','$genderSelect','$state','$city','$date')";
$data=mysqli_query($conn,$query);
if($data)
{
echo '<script>alert("Successfully registered!")</script>';
}
else
echo 'insert all data';
//echo $fname .'<br>';
//echo $lname .'<br>';
//echo $age .'<br>';
}
?>
</div>
<script src="https://code.jquery.com/jquery-3.5.1.slim.min.js" integrity="sha384-DfXdz2htPH0lsSSs5nCTpuj/zy4C+OGpamoFVy38MVBnE+IbbVYUew+OrCXaRkfj" crossorigin="anonymous"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/umd/popper.min.js" integrity="sha384-9/reFTGAW83EW2RDu2S0VKaIzap3H66lZH81PoYlFhbGU+6BZp6G7niu735Sk7lN" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/js/bootstrap.min.js" integrity="sha384-B4gt1jrGC7Jh4AgTPSdUtOBvfO8shuf57BaghqFfPlYxofvL8/KUEfYiJOMMV+rV" crossorigin="anonymous"></script>
</body>
</html>