muzima-form/MotorbikesAccidentsEncounterForm.html at master · muzima/muzima-form · GitHub

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<html>
<head>
    <meta name="viewport" content="width=device-width, initial-scale=1">
    <link href="css/bootstrap.min.css" rel="stylesheet">
    <link href="css/muzima.css" rel="stylesheet">
    <link href="css/ui-darkness/jquery-ui-1.10.4.custom.min.css" rel="stylesheet">

    <script src="js/jquery.min.js"></script>
    <script src="js/jquery-ui-1.10.4.custom.min.js"></script>
    <script src="js/jquery.validate.min.js"></script>
    <script src="js/additional-methods.min.js"></script>
    <script src="js/muzima.js"></script>
    <title>Motorbike Accidents Encounter Form V0.01</title>
    <style>
    </style>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data">
</div>
<form id="motorbike_accidents_form" name="motorbike_accidents_form">

<h2 class="text-center">Motorbike Accidents Encounter Form V0.01</h2>

<div class="section">
    <h3>Demographics</h3>
    <div class="form-group">
        <input class="form-control" id="patient.uuid"
               name="patient.uuid" type="hidden" readonly="readonly">
    </div>
    <div class="form-group">
        <label for="patient.medical_record_number">AMRS ID Number:</label>
        <input class="form-control" id="patient.medical_record_number"
               name="patient.medical_record_number" type="text" readonly="readonly">
    </div>
    <div class="form-group">
        <label for="patient.family_name">Family Name:</label>
        <input class="form-control" id="patient.family_name" name="patient.family_name" type="text"
               readonly="readonly">
    </div>
    <div class="form-group">
        <label for="patient.given_name">Given Name:</label>
        <input class="form-control" id="patient.given_name" name="patient.given_name" type="text"
               readonly="readonly">
    </div>
    <div class="form-group">
        <label for="patient.middle_name">Middle Name:</label>
        <input class="form-control" id="patient.middle_name" name="patient.middle_name" type="text"
               readonly="readonly">
    </div>
    <div class="form-group">
        <label for="patient.sex">Gender:</label>
        <select class="form-control" id="patient.sex" name="patient.sex" disabled="disabled">
            <option value="">...</option>
            <option value="M">Male</option>
            <option value="F">Female</option>
        </select>
    </div>
    <div class="form-group">
        <label for="patient.birth_date">Date Of Birth:</label>
        <input class="form-control" id="patient.birth_date" name="patient.birth_date" type="text"
               readonly="readonly" value="">
    </div>
</div>
<div class="section">
    <h3>Encounter Details</h3>

    <div class="form-group">
        <label for="encounter.location_id">Name of Health Center:<span class="required">*</span></label>
        <input class="form-control" id="encounter.location_id" type="text" placeholder="Start typing something...">
        <input class="form-control" name="encounter.location_id" type="hidden">
    </div>

    <div class="form-group">
        <label for="encounter.provider_id_select">Provider Name:<span class="required">*</span></label>
        <input class="form-control" id="encounter.provider_id_select" type="text" placeholder="Start typing something...">
        <input class="form-control" name="encounter.provider_id_select" type="hidden">
    </div>

    <div class="form-group show_provider_id_text">
        <label for="encounter.provider_id">Provider system-id:<span class="required">*</span></label>
        <input class="form-control checkDigit" id="encounter.provider_id" disabled name="encounter.provider_id"
               type="text" required="required"  placeholder="Provider Id">
    </div>
    <div class="form-group">
        <label for="encounter.encounter_datetime">Encounter Date:<span class="required">*</span></label>
        <input class="form-control datepicker nonFutureDate" id="encounter.encounter_datetime"
               name="encounter.encounter_datetime" type="text" readonly="readonly"
               required="required">
    </div>
    <div class="form-group">
        <input class="form-control" id="encounter.form_uuid" name="encounter.form_uuid"
               type="hidden" required="required">
    </div>
</div>
<div class="section">
    <div class="form-group">
        </p><label for="obs.number_of_victims">How many victims were involved in the accident?  </label>
        <input class="form-control" id="obs.number_of_victims" name="obs.number_of_victims"
               type="number" placeholder="Number of Victims" data-concept="9258^How many victims were involved in the accident?^99DCT" required="required">
    </div>
    <div>
        <label for="obs.date_of_accident">When did the accident take place:</label>
        <input class="form-control datepicker past-date" data-concept="9259^When did the accident take place^99DCT"
               id="obs.date_of_accident" name="obs.date_of_accident" type="text"
               readonly="readonly">
    </div>
    <div class="form-group">
        <label for="obs.accident_location">Where did the accident happen?
            <span class="required">*</span>
        </label>
        <input class="form-control" id="obs.accident_location"
               name="obs.accident_location" type="text" require="required"
               data-concept="9260^Where did the accident happen^99DCT">
    </div>
    <div class="form-group">
    <label for="obs.injury_suffered">Did you suffer injuries?<span class="required">*</span></label>
        <select class="form-control" id="obs.injury_suffered" name="obs.injury_suffered" required="required"
            data-concept="9261^Did you suffer injuries?^99DCT">
            <option value="">...</option>
            <option value="1065^YES^99DCT">Yes</option>
            <option value="1066^NO^99DCT">No</option>
        </select>
    </div>
     <div class="form-group">
    <label for="obs.blood_group">5. What’s your blood group?<span class="required">*</span></label>
        <select class="form-control" id="obs.blood_group" name="obs.blood_group" required="required"
            data-concept="300^BLOOD TYPING^99DCT">
            <option value="">...</option>
            <option value="6420^A^99DCT">A</option>
            <option value="6421^B^99DCT">B</option>
            <option value="6422^AB^99DCT">AB</option>
            <option value="6423^O^99DCT">O</option>
        </select>
    </div>
</div>

<script type="text/javascript">

$(document).ready(function () {
    $('#motorbike_accidents_form').validate({
        rules: {
            'obs.number_of_victims': {
                number: true,
                range: [1, 100]
            }
        }
    });

    $('#save_draft').click(function () {
        $(this).prop('disabled', true);
        document.saveDraft(this);
        $(this).prop('disabled', false);
    });

    $('#submit_form').click(function () {
        $(this).prop('disabled', true);
        document.submit();
        $(this).prop('disabled', false);
    });
});
</script>
</html>