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prescriptionformat.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1">
<!-- The above 3 meta tags *must* come first in the head; any other head content must come *after* these tags -->
<title>SMART CLINIC </title>
<meta name="description" content="Course files for the most awesome Bootstrap 3 course on Udemy.">
<meta name="author" content="Muhammad Bilal">
<!-- Bootstrap & Fontawesome -->
<link href="assets/css/bootstrap.css" rel="stylesheet">
<link href="assets/css/font-awesome.min.css" rel="stylesheet">
<link href="assets/themes/united.css" rel="stylesheet">
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.12.2/jquery.min.js"></script>
<!-- HTML5 shim and Respond.js for IE8 support of HTML5 elements and media queries -->
<!-- WARNING: Respond.js doesn't work if you view the page via file:// -->
<!--[if lt IE 9]>
<script src="https://oss.maxcdn.com/html5shiv/3.7.2/html5shiv.min.js"></script>
<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
<![endif]-->
<!-- Start Inline CSS. (This overrides all of the above styles) -->
<!-- End Inline CSS -->
<body role="document">
<!-- Fixed navbar -->
<nav class="navbar navbar-inverse navbar-fixed-top">
<div class="container">
<div class="navbar-header">
<button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navbar" aria-expanded="false" aria-controls="navbar">
<span class="sr-only">Toggle navigation</span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
</button>
<a href="#"><img src="newlogo2.png" class="img-responsive" alt="Picture not loaded" ></a>
</div>
<div id="navbar" class="navbar-collapse collapse"style="padding-top: 0px;">
<ul class=" navbar-right list-inline"style="padding-top: 8px;">
<li class="dropdown">
<a href="" class="btn btn-default" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-haspopup="true" aria-expanded="false">Sign Up <span class="caret"></span></a>
<ul class="dropdown-menu">
<li><a href="User sign up.html">User Sign up</a></li>
<li role="separator" class="divider"></li>
<li><a href="Doctor Sign up.html">Doctor Sign up</a></li>
</li>
</ul>
<li><a href="login pannel.html" class="btn btn-default">Log In</a></li>
</ul>
<ul class="nav navbar-nav ">
<li class="active"><a href="index.html">Home</a></li>
<li><a href="#about">About</a></li>
<li><a href="#contact">Contact</a></li>
<li class="dropdown">
<a href="#" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-haspopup="true" aria-expanded="false">Dropdown <span class="caret"></span></a>
<ul class="dropdown-menu">
<li><a href="#">Action</a></li>
<li><a href="#">Another action</a></li>
<li><a href="#">Something else here</a></li>
<li role="separator" class="divider"></li>
<li class="dropdown-header">Nav header</li>
<li><a href="#">Separated link</a></li>
<li><a href="#">One more separated link</a></li>
</ul>
</li>
</ul>
</div><!--/.nav-collapse -->
</div>
</nav>
</head>
<STYLE TYPE="text/css">
.jumbotron,
.page {
padding-top: 140px;
padding-bottom: 140px;
margin-bottom: 0px;
}
</STYLE>
<div class="text-center">
<div class="jumbotron">
<h1>Prescription View</h1>
<p>This is a template showcasing the optional theme stylesheet included in Bootstrap. Use it as a starting point to create something more unique by building on or modifying it.</p>
</div>
</div>
<br>
<div class="multi-field col-sm-1">
<label>Name:</label><h5>Get name</h5>
</div>
<div class="multi-field col-sm-1">
<label>NIC:</label><h5>Get NIC</h5>
</div>
<div class="multi-field col-sm-1">
<label>Date:</label><h5>Get Date</h5>
</div>
<br><br><br><br><br>
<section>
<form action="" method="POST">
<div class="container">
<h2>Chief Compalints</h2>
</div>
<div class="well text-left">
<div class="multi-field-wrapper">
<div class="multi-fields">
<div class="multi-field col-sm-12">
<div class="form-group col-sm-4">
<label>Complaint</label>
<input type="text" class="form-control" name="complaint[]"placeholder="Your Medicine Name">
</div>
<button type="button" class="remove-field col-sm-0 btn btn-default" style="margin-top:24px;">
<span class="glyphicon glyphicon glyphicon-remove"></span></button>
</div>
</div>
<div class="text-center">
<button type="button" class="add-field btn btn-default">Add more Chief Complaints</button>
</div>
</div>
</div>
<div class="container">
<h2>On Examination</h2>
</div>
<div class="well text-left">
<div class="multi-field-wrapper">
<div class="multi-fields">
<div class="multi-field col-sm-12">
<div class="form-group col-sm-4">
<label>Examination</label>
<input type="text" class="form-control" name="examination[]"placeholder="Your Medicine Name">
</div>
<button type="button" class="remove-field col-sm-0 btn btn-default" style="margin-top:24px;">
<span class="glyphicon glyphicon glyphicon-remove"></span></button>
</div>
</div>
<div class="text-center">
<button type="button" class="add-field btn btn-default">Add more Examinations</button>
</div>
</div>
</div>
<div class="container">
<h2>Medicines</h2>
</div>
<div class="well text-left">
<div class="multi-field-wrapper">
<div class="multi-fields">
<div class="multi-field col-sm-12">
<div class="form-group col-sm-4">
<label>Drug Prescribed</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Stength</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Quantity</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Dosage</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Start Date</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>End Date</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Instructional Notes</label>
<input type="text" class="form-control" name="frequency[]"placeholder="Enter miligrams of medicine">
</div>
<div class="form-group col-sm-3">
<label>Form</label>
<select class="form-control" name="form[]">
<option>Capsule</option>
<option>Tablet</option>
<option>Liquid</option>
</select>
</div>
<div class="form-group col-sm-3">
<label>Route</label>
<select class="form-control" name="route[]">
<option>Oral</option>
<option>Inject</option>
</select>
</div>
<div class="form-group col-sm-3">
<label>Frequency</label>
<select class="form-control" name="frequency[]">
<option>Once a day</option>
<option>Twice a day</option>
<option>Thrice a day</option>
</select>
</div>
<button type="button" class="remove-field col-sm-0 btn btn-default" style="margin-top:24px;">
<span class="glyphicon glyphicon glyphicon-remove"></span></button>
</div>
</div>
<div class="text-center">
<button type="button" class="add-field btn btn-default">Add more Medicine details</button>
</div>
</div>
</div>
<div class="container">
<h2>Comments By Doctor</h2>
</div>
<div class="well">
<textarea class="form-control" rows="3" name="comments" placeholder="Enter miligrams of medicine"></textarea>
</div>
<div class="well text-center">
<button type="submit" class="btn btn-default">Submit</button>
</div>
</form>
<br><br><br><br>
<hr>
<footer>
<div class=" text-center">
<h3>Enter your name and email</h3>
<form action="" method="" class="form-inline">
<div class="form-group">
<label for="Name">Name</label>
<input type="text" class="form-control" id="subscription" placeholder="Your name">
</div>
<div class="form-group">
<label for="email">Email address</label>
<input type="text" class="form-control" id="email" placeholder="Enter your Email">
</div>
<button type="submit" class="btn btn-default">Subscribe</button>
</form>
<br>
<hr>
<div class="btn-group">
<a class="btn btn-md btn-info" href="http://www.twitter.com/">Twitter</a>
<a class="btn btn-md btn-info" href="http://www.facebook.com/">Facebook</a>
<a class="btn btn-md btn-info" href="http://www.youtube.com/">YouTube</a>
</div>
<br>
<hr>
<span class="label label-info" >© Copyright Muhammad Bilal, Muhammad Irfan, Zar Mashal @ 2015</span>
</div><!-- end Container-->
</footer>
<script type="text/javascript">
$('.multi-field-wrapper').each(function() {
var $wrapper = $('.multi-fields', this);
$(".add-field", $(this)).click(function(e) {
$('.multi-field:first-child', $wrapper).clone(true).appendTo($wrapper).find('input').val('').focus();
});
$('.multi-field .remove-field', $wrapper).click(function() {
if ($('.multi-field', $wrapper).length > 1)
$(this).parent('.multi-field').remove();
});
});
</script>
<!-- jQuery (necessary for Bootstrap's JavaScript plugins) -->
<script src="assets/js/jquery.min.js"></script>
<!-- Include all compiled plugins (below), or include individual files as needed -->
<script src="assets/js/bootstrap.min.js"></script>
<!-- Start JS Config (This is where you configure the Bootstrap JS options) -->
<!-- End JS Config -->
</body>
</html>