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<!DOCTYPE html>
<html lang="en" dir="ltr">
<head>
<meta charset="utf-8">
<title></title>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta http-equiv="X-UA-Compatible" content="ie=edge">
<title>Document</title>
<script src="https://kit.fontawesome.com/e034c117a5.js" crossorigin="anonymous"></script>
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.4.1/css/bootstrap.min.css" integrity="sha384-Vkoo8x4CGsO3+Hhxv8T/Q5PaXtkKtu6ug5TOeNV6gBiFeWPGFN9MuhOf23Q9Ifjh" crossorigin="anonymous">
<link href="https://fonts.googleapis.com/css?family=Roboto:900&display=swap" rel="stylesheet">
<script src="https://code.jquery.com/jquery-3.4.1.slim.min.js" integrity="sha384-J6qa4849blE2+poT4WnyKhv5vZF5SrPo0iEjwBvKU7imGFAV0wwj1yYfoRSJoZ+n" crossorigin="anonymous"></script>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/popper.js@1.16.0/dist/umd/popper.min.js" integrity="sha384-Q6E9RHvbIyZFJoft+2mJbHaEWldlvI9IOYy5n3zV9zzTtmI3UksdQRVvoxMfooAo" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.4.1/js/bootstrap.min.js" integrity="sha384-wfSDF2E50Y2D1uUdj0O3uMBJnjuUD4Ih7YwaYd1iqfktj0Uod8GCExl3Og8ifwB6" crossorigin="anonymous"></script>
<script src="https://maps.googleapis.com/maps/api/js?key=AIzaSyAa8HeLH2lQMbPeOiMlM9D1VxZ7pbGQq8o&callback=initMap" async defer></script>
<!-- <link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.0/css/bootstrap.min.css"> -->
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.4.0/jquery.min.js"></script>
<!-- <script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.0/js/bootstrap.min.js"></script> -->
<script src="http://code.jquery.com/jquery-1.5.js"></script>
<!-- <link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> -->
<!-- <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> -->
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<!-- CSS only -->
<!-- <link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.5.0/css/bootstrap.min.css" integrity="sha384-9aIt2nRpC12Uk9gS9baDl411NQApFmC26EwAOH8WgZl5MYYxFfc+NcPb1dKGj7Sk" crossorigin="anonymous"> -->
<!-- JS, Popper.js, and jQuery -->
<!-- <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/popper.js@1.16.0/dist/umd/popper.min.js" integrity="sha384-Q6E9RHvbIyZFJoft+2mJbHaEWldlvI9IOYy5n3zV9zzTtmI3UksdQRVvoxMfooAo" crossorigin="anonymous"></script> -->
<!-- <script src="https://stackpath.bootstrapcdn.com/bootstrap/4.5.0/js/bootstrap.min.js" integrity="sha384-OgVRvuATP1z7JjHLkuOU7Xw704+h835Lr+6QL9UvYjZE3Ipu6Tp75j7Bh/kR0JKI" crossorigin="anonymous"></script> -->
<!------ Include the above in your HEAD tag ---------->
<!-- Social Footer, Colour Matching Icons -->
<!-- Include Font Awesome Stylesheet in Header -->
<!-- <link href="//maxcdn.bootstrapcdn.com/font-awesome/4.1.0/css/font-awesome.min.css" rel="stylesheet"> -->
<link rel="stylesheet" href="css/styles.css">
<link rel="stylesheet" href="css/glyphicon.css">
</head>
<body>
<script type="text/javascript">
$(document).ready(function() {
var text_max = 3000;
$('#textarea_feedback').html(text_max + ' characters remaining');
$('#textarea').keyup(function() {
var text_length = $('#textarea').val().length;
var text_remaining = text_max - text_length;
$('#textarea_feedback').html(text_remaining + ' characters remaining');
});
});
</script>
<nav id="navbar-example2" class="navbar fixed-top navbar-expand-lg nav navbar-dark bg-dark rel" style="background-color: #01091c !important">
<a class="navbar-brand" href="#">
<img src="img/srm.png" alt="" id="logo">
</a>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#navbarNav" aria-controls="navbarNav" aria-expanded="false" aria-label="Toggle navigation">
<span class="navbar-toggler-icon"></span>
</button>
<div class="collapse navbar-collapse" id="navbarNav">
<ul class="navbar-nav">
<li class="nav-item ">
<a class="nav-link" href="index.php">Home</a>
</li>
<li class="nav-item">
<a class="nav-link" href="index.php#symp">symptoms</a>
</li>
<li class="nav-item">
<a class="nav-link" href="index.php#symp">Prevention</a>
</li>
<li class="nav-item">
<a class="nav-link " href="#stats" >Stats</a>
</li>
<li class="nav-item">
<a class="nav-link " href="#contact">Contact</a>
</li>
<li class="nav-item">
<a class="nav-link " href="stat.php">View Status</a>
</li>
<li class="nav-item">
<div id="google_translate_element" ></div>
</li>
</ul>
</div>
</nav>
<div class="containerr container ">
<h1 style="color: #00b7c2;text-align:center">Patient Form</h1>
</div>
<div class="container center-form">
<!-- <h2>Patient Details:- </h2> -->
<br>
<form class="Details" method="post" id="patientForm">
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="name">Name</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span><input id="name" name="name" placeholder="Enter Full Name here..." class="form-control" required="true" value="" type="text"></div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="gender">Gender</label>
<label class="radio-inline">
<input id="gender" type="radio" name="gender" value='Male' checked>Male
</label>
<label class="radio-inline">
<input id="gender" type="radio" name="gender" value="Female" >Female
</label>
<label class="radio-inline">
<input id="gender" type="radio" name="gender" value="Transgender" >Transgender
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="address">Address</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span><input id="address" name="address" placeholder="Enter Address here..." class="form-control" required="true" value="" type="text"></div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="pincode">Pincode</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span><input id="pincode" name="pincode" placeholder="Enter Pincode here..." class="form-control" required="true" value="" type="text"></div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="sell">State</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon" style="max-width: 100%;"><i class="glyphicon glyphicon-list"></i></span>
<select class="selectpicker form-control" name='state' id="state">
<option>Andhra Pradesh</option>
<option>Arunachal Pradesh</option>
<option>Assam</option>
<option>Bihar</option>
<option>Chhatisgarh</option>
<option>Goa</option>
<option>Gujarat</option>
<option>Haryana</option>
<option>Himachal Pradesh</option>
<option>Jammu and KAshmir</option>
<option>Jharkhand</option>
<option>Karnataka</option>
<option>Kerala</option>
<option>Madhya Pradesh</option>
<option>Maharashtra</option>
<option>Manipur</option>
<option>Meghalaya</option>
<option>Mizoram</option>
<option>Nagaland</option>
<option>Odisha</option>
<option>Punjab</option>
<option>Rajasthan</option>
<option>Sikkim</option>
<option>Tamil Nadu</option>
<option>Telangana</option>
<option>Tripura</option>
<option>Uttar Pradesh</option>
<option>Uttarakhand</option>
<option>West Bengal</option>
</select>
</div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="age">Age Group</label>
<label class="radio-inline">
<input id="age" type="radio" name="age" value = "0-9" checked>0-9
</label>
<label class="radio-inline">
<input id="age" type="radio" name="age" value="10-19" >10-19
</label>
<label class="radio-inline">
<input id="age" type="radio" name="age" value="20-24" >20-24
</label>
<label class="radio-inline">
<input id="age" type="radio" name="age" value="25-59" >25-59
</label>
<label class="radio-inline">
<input id="age" type="radio" name="age" value="60+" >60+
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="phono">Phone Number</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span><input id="phoneNumber" name="phone" placeholder="Enter Phone Number here..." class="form-control" required="true" type="text"></div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="email">Email-ID</label>
<div class="col-md-8 inputGroupContainer">
<div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span><input id="email" name="email" placeholder="Enter Email here.." class="form-control" required="true" type="email"></div>
</div>
</div>
<h1 style="color: #00b7c2;text-align:center; width:100%; margin:30px 0"> Symptoms</h2>
<div class="form-group row">
<!-- <br /> -->
<label class="col-sm-4 col-form-label" for="no_symptoms">No Symptoms</label>
<label class="radio-inline">
<input id="noSymptom" type="radio" name="no_symptoms" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="noSymptom" type="radio" name="no_symptoms" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="fever">Fever</label>
<label class="radio-inline">
<input id="fever" type="radio" name="fever" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="fever" type="radio" name="fever" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="tiredness">Tiredness</label>
<label class="radio-inline">
<input id="tiredness" type="radio" name="tiredness" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="tiredness" type="radio" name="tiredness" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="dry_cough">Dry Cough</label>
<label class="radio-inline">
<input id="dryCough" type="radio" name="dry_cough" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="dryCough" type="radio" name="dry_cough" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="difficulty_in_breathing">Difficulty in breathing</label>
<label class="radio-inline">
<input id="difficultyBreathing" type="radio" name="difficulty_in_breathing" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="difficultyBreathing" type="radio" name="difficulty_in_breathing" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="sore_throat">Sore Throat</label>
<label class="radio-inline">
<input id="soreThroat" type="radio" name="sore_throat" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="soreThroat" type="radio" name="sore_throat" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="pain">Pain</label>
<label class="radio-inline">
<input id="pain" type="radio" name="pain" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="pain" type="radio" name="pain" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="nasal_congestion">Nasal Congestion</label>
<label class="radio-inline">
<input id="nasalCongestion" type="radio" name="nasal_congestion" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="nasalCongestion" type="radio" name="nasal_congestion" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="runny_nose">Runny Nose</label>
<label class="radio-inline">
<input id="runnyNose" type="radio" name="runny_nose" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="runnyNose" type="radio" name="runny_nose" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="diarrhea">Diarrhea</label>
<label class="radio-inline">
<input id="diarrhea" type="radio" name="diarrhea" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="diarrhea" type="radio" name="diarrhea" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="none_experiencing">None Experiencing</label>
<label class="radio-inline">
<input id="noneExperiencing" type="radio" name="none_experiencing" value = "0" checked>No
</label>
<label class="radio-inline">
<input id="noneExperiencing" type="radio" name="none_experiencing" value="1" >Yes
</label>
</div>
<div class="form-group row">
<label class="col-sm-4 col-form-label" for="textarea">Enter your request here</label>
<div class="col-xs-5">
<textarea id="textarea" class="form-control"rows="8" cols="100" maxlength="3000" name="question" placeholder = "Enter your query here..." required="true"></textarea>
<div id="textarea_feedback"></div>
</div>
</div>
<div class="form-group row">
<div class="col-sm-offset-4 col-sm-10" style="text-align:center">
<button id="submit" type="submit" class="btn btn-primary" name="submit">Submit</button>
<button type="reset" class="btn btn-primary">Reset</button>
<!-- <iframe src="https://www.google.com/maps/embed?pb=!1m18!1m12!1m3!1d13447.133591780499!2d80.9108633809512!3d26.829400928546686!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x399bfdc8bfb928d5%3A0x9f9163ace7ebaf6c!2sCharbagh%2C%20Lucknow%2C%20Uttar%20Pradesh!5e0!3m2!1sen!2sin!4v1591027989869!5m2!1sen!2sin" width="400" height="400" frameborder="0" style="border:0; margin-left: 50px" aria-hidden="false" tabindex="0"></iframe> -->
</div>
</div>
</div>
</form>
<div class="alert">Your response has been recorded. Your ID is : [<span style="font-size: 1.2em; color: rgb(227,216,114)" id="newPostID"></span>]. Please copy this and save it somewhere. Our AI model would process your symptoms and your result will be generated in a couple of minutes. You can check your results in the "View Status" page. Our team works with 100% efficiency towards bringing SOLACE to you in this time of pandemic.</div>
</div>
<div class="tracker row" id="stats">
<iframe class="col-xs-12 col-md-6" style="margin-left: 60px" src="https://app.developer.here.com/coronavirus/" frameborder="0"></iframe>
</div>
<div class="row footer" id="contact">
<div class=" col-xs-12 col-md-12 footer-top">
<ul>
<li> <a href="#"> <i class="fas fa-envelope"></i></li></a>
<li> <a href="#"><i class="fab fa-twitter"></i></li></a>
<li> <a href="#"><i class="fab fa-facebook"></i></li></a>
<li> <a href="#"><i class="fab fa-instagram"></i></li></a>
</ul>
</div>
<div class="col-xs-12 col-md-12 footer-bottom">
<p>Made with ❤️ ©2020 Solace</p>
</div>
</div>
<script src="https://www.gstatic.com/firebasejs/7.14.6/firebase-app.js"></script>
<script src="https://www.gstatic.com/firebasejs/7.14.6/firebase-analytics.js"></script>
<script src="https://www.gstatic.com/firebasejs/7.14.6/firebase-database.js"></script>
<script type="text/javascript" src="main.js"></script>
<!-- <script type="text/javascript" src="scripts/script.js"></script> -->
<script type="text/javascript">
function googleTranslateElementInit() {
new google.translate.TranslateElement({pageLanguage: 'en'}, 'google_translate_element');
}
</script>
<script type="text/javascript" src="//translate.google.com/translate_a/element.js?cb=googleTranslateElementInit"></script>
</body>
</html>