API tools faq
paste
Advertisement
rafisbr

input_pasien.php

rafisbr
May 5th, 2022
41
0
Never
Add comment
Not a member of Pastebin yet? Sign Up, it unlocks many cool features!
text 13.33 KB | None | 0 0
raw download clone embed print report
  1. <?php include '../widgets/header.php'; ?>
  2.  
  3. <body>
  4.  
  5. <!-- ======= Header ======= -->
  6. <?php include '../widgets/topbar.php'; ?>
  7. <!-- End Header -->
  8.  
  9. <!-- ======= Sidebar ======= -->
  10. <?php include '../widgets/sidebar.php' ?>
  11. <!-- End Sidebar-->
  12.  
  13. <main id="main" class="main">
  14.  
  15. <div class="pagetitle">
  16. <h1>FORM INPUT PASIEN</h1>
  17. <nav>
  18. <ol class="breadcrumb">
  19. <li class="breadcrumb-item"><a href="home.php">Home</a></li>
  20. <li class="breadcrumb-item"><a href="data_pasien.php">Data Pasien</a></li>
  21. <li class="breadcrumb-item active">Input Pasien</li>
  22. </ol>
  23. </nav>
  24. </div><!-- End Page Title -->
  25.  
  26. <section class="section">
  27. <div class="row">
  28. <div class="col-lg-12">
  29.  
  30. <div class="card">
  31. <div class="card-body">
  32. <h5 class="card-title">Input Pasien</h5>
  33.  
  34. <!-- General Form Elements -->
  35. <form action="../api/input_pasiens.php" method="POST">
  36.  
  37. <input id="id_pasien" name="id_pasien" value="<?php echo $idPasien ?>" type="hidden" class="form-control" />
  38.  
  39. <!-- Nama Pasien -->
  40. <div class="col-12 position-relative">
  41. <div class="form-floating mb-3">
  42. <input type="text" class="form-control" id="floatingPasien" name="nm" onkeyup="myFunction()" placeholder="Masukkan Nama Pasien" required>
  43. <label for="floatingPasien">Nama Pasien</label>
  44. <div class="invalid-tooltip">
  45. Nama Pasien Tidak Boleh Kosong!
  46. </div>
  47. </div>
  48. </div>
  49.  
  50. <!-- Jenis Kelamin -->
  51. <div class="col-12">
  52. <div class="form-floating mb-3">
  53. <select class="form-select" aria-label="Default select example" id="floatingJk" name="jk" required>
  54. <option selected>Pilih Jenis Kelamin</option>
  55. <option value="laki">Laki - Laki</option>
  56. <option value="perempuan">Perempuan</option>
  57. </select>
  58. <label for="floatingJk">Pilih Jenis Kelamin</label>
  59. <div class="invalid-tooltip">
  60. Jenis Kelamin Tidak Boleh Kosong!
  61. </div>
  62. </div>
  63. </div>
  64.  
  65. <!-- Tanggal Lahir -->
  66. <div class="col-12">
  67. <div class="form-floating mb-3">
  68. <input type="date" class="form-control" id="floatingDate" name="tgl_lahir">
  69. <label for="floatingDate">Tanggal Lahir</label>
  70. <div class="invalid-tooltip">
  71. Tanggal Lahir Tidak Boleh Kosong
  72. </div>
  73. </div>
  74. </div>
  75.  
  76.  
  77. <div class="col-12">
  78. <div class="form-floating mb-3">
  79. <select class="form-select" aria-label="Default select example" id="floatingStatus" name="status">
  80. <option selected>Pilih Status Pasien</option>
  81. <option value="pekerja">Pekerja</option>
  82. <option value="suami_istri">Istri/Suami Pekerja</option>
  83. <option value="anak Pekerja">Anak Pekerja</option>
  84. <option value="umum">Umum</option>
  85. </select>
  86. <label for="floatingStatus">Status Pasien</label>
  87. <div class="invalid-tooltip">
  88. Status Pasien Tidak Boleh Kosong!
  89. </div>
  90. </div>
  91. </div>
  92.  
  93. <div class="col-12">
  94. <!-- <label class="form-label">Nama Pekerja</label> -->
  95. <div class="form-floating mb-3">
  96. <input type="text" class="form-control" id="floatingPekerja" name="nama_pekerja" onkeyup="myFunction1()" placeholder="Masukkan Nama Pekerja" required>
  97. <label for="floatingPekerja">Nama Pekerja</label>
  98. <div class="invalid-tooltip">
  99. Nama Pekerja Tidak Boleh Kosong!
  100. </div>
  101. </div>
  102. </div>
  103.  
  104. <div class="col-12">
  105. <div class="form-floating mb-3">
  106. <select class="form-select" aria-label="Default select example" id="floatingJabatan" name="jabatan">
  107. <option selected>Pilih Jabatan Pekerja</option>
  108. <option value="1">Act. Askep ESD</option>
  109. <option value="2">Act. Askep Nursery </option>
  110. <option value="3">Act. Mgr Pangkor</option>
  111. <option value="4">Act. Mgr Pasir Salak</option>
  112. <option value="5">Adm. Kebun</option>
  113. <option value="6">Agt. Keamanan</option>
  114. <option value="7">Analis Laboratorium</option>
  115. <option value="8">Anggota</option>
  116. <option value="9">Askep</option>
  117. <option value="10">Askep Grik I & Ast.Lap. OP'05 A</option>
  118. <option value="11">Askep Grik II & Ast.Lap. OP'06 A</option>
  119. <option value="12">Askep Humas</option>
  120. <option value="13">Askep Operational dan Maintenance</option>
  121. <option value="14">Askep Pangkor I & Ast. Lap. OP'98 B</option>
  122. <option value="15">Askep Pangkor II & Ast. Lap. OP'99</option>
  123. <option value="16">askep Pasir Salak I & Ast. Lap. OP'97 B</option>
  124. <option value="17">Askep Pasir Salak II & Ast. Lap OP'98 D</option>
  125. <option value="18">Askep Produksi</option>
  126. <option value="19">Assistant Accounting</option>
  127. <option value="20">Assistant Accounting II</option>
  128. <option value="21">Assistant Admin Palembang</option>
  129. <option value="22">Assistant Elektrikal</option>
  130. <option value="23">Assistant Finance</option>
  131. <option value="24">Assistant Lapangan OP'06 B</option>
  132. <option value="25">Assistant Lapangan OP'2007 A</option>
  133. <option value="26">Assistant Lapangan OP'2007 B</option>
  134. <option value="27">Assistant Lapangan OP'2008</option>
  135. <option value="28">Assistant Lapangan OP'96</option>
  136. <option value="29">Assistant Lapangan OP'97 A</option>
  137. <option value="30">Assistant Lapangan OP'97 C</option>
  138. <option value="31">Assistant Lapangan OP'98 A</option>
  139. <option value="32">Assistant Lapangan OP'98 C</option>
  140. <option value="33">Assistant Lapangan OP'98 D</option>
  141. <option value="34">Assistant Marketing</option>
  142. <option value="35">Assistant MTC</option>
  143. <option value="36">Assistant Personalia</option>
  144. <option value="37">Assistant Poliklinik</option>
  145. <option value="38">Assistant Proses PKS</option>
  146. <option value="39">Assistant QC Air Boiler, WT & Limbah</option>
  147. <option value="40">Assistant QC Peng. Produksi</option>
  148. <option value="41">Assistant Sortasi</option>
  149. <option value="42">Assistant Sustainability</option>
  150. <option value="43">Assistant Task Force</option>
  151. <option value="44">Assistant Transport</option>
  152. <option value="45">Assistant Workshop</option>
  153. <option value="46">Bidan Poliklinik BC-RO</option>
  154. <option value="47">Bidan Poliklinik Grik</option>
  155. <option value="48">Bidan Poliklinik PKS</option>
  156. <option value="49">Bilal Masjid</option>
  157. <option value="50">Danru</option>
  158. <option value="51">Danru Keamanan</option>
  159. <option value="52">Danton Security</option>
  160. <option value="53">Deputy Executive Director</option>
  161. <option value="54">Dokter Poliklinik</option>
  162. <option value="55">Driver FC</option>
  163. <option value="56">Effluent Pond</option>
  164. <option value="57">Electrical</option>
  165. <option value="68">ESD</option>
  166. <option value="59">Executive Director</option>
  167. <option value="60">Financial Controller</option>
  168. <option value="61">General Manager</option>
  169. <option value="62">Guru</option>
  170. <option value="63">Head Sortasi</option>
  171. <option value="64">Imam Masjid</option>
  172. <option value="65"> </option>
  173. <option value="66"> </option>
  174. <option value="67"> </option>
  175. <option value="68"> </option>
  176. <option value="67"> </option>
  177. <option value="70"> </option>
  178. <option value="71"> </option>
  179. <option value="72"> </option>
  180. <option value="73"> </option>
  181. <option value="74"> </option>
  182. <option value="75"> </option>
  183. <option value="76"> </option>
  184. <option value="77"> </option>
  185. <option value="78"> </option>
  186. <option value="79"> </option>
  187. <option value="80"> </option>
  188. <option value="81"> </option>
  189. <option value="82"> </option>
  190. <option value="83"> </option>
  191. <option value="84"> </option>
  192. <option value="85"> </option>
  193. <option value="86"> </option>
  194. <option value="87"> </option>
  195. <option value="88"> </option>
  196. <option value="89"> </option>
  197. <option value="90"> </option>
  198. <option value="91"> </option>
  199. <option value="92"> </option>
  200. <option value="93"> </option>
  201. <option value="94"> </option>
  202. <option value="95"> </option>
  203. <option value="96"> </option>
  204. <option value="97"> </option>
  205. <option value="98"> </option>
  206. <option value="99"> </option>
  207. <option value="100"> </option>
  208.  
  209.  
  210. </select>
  211. <!-- <label for="floatingJabatan">Jabatan</label> -->
  212. </div>
  213. </div>
  214.  
  215. <div class="col-12">
  216. <div class="form-floating mb-3">
  217. <select class="form-select" aria-label="Default select example" id="floatingStatusPekerja" name="golongan">
  218. <option selected>Pilih Status Pekerja</option>
  219. <option value="executive">Executive</option>
  220. <option value="pb">PB</option>
  221. <option value="pght">PGHT</option>
  222. <option value="bhl">BHL</option>
  223. <option value="brg">BRG</option>
  224. <option value="umum">UMUM</option>
  225. </select>
  226. <label for="floatingStatusPekerja">Status Pekerja</label>
  227. </div>
  228. </div>
  229.  
  230. <div class="col-12">
  231. <div class="form-floating mb-3">
  232. <select class="form-select" aria-label="Default select example" id="floatingEstate" name="estate">
  233. <option selected>Pilih Estate Pekerja</option>
  234. <option value="ro">Regional Office</option>
  235. <option value="psalak">Pasir Salak</option>
  236. <option value="pangkor">Pangkor</option>
  237. <option value="grik">Grik</option>
  238. <option value="pks">PKS</option>
  239. <option value="umum">Umum</option>
  240. </select>
  241. <label for="floatingEstate">Estate Pekerja</label>
  242. </div>
  243. </div>
  244.  
  245. <div class="col-12">
  246. <div class="form-floating mb-3">
  247. <select class="form-select" aria-label="Default select example" id="floatingOp" name="op">
  248. <option selected>Pilih OP Pekerja</option>
  249. <option value="ro">RO</option>
  250. <option value="pks">PKS</option>
  251. <option value="op96">OP 96</option>
  252. <option value="op97a">OP 97A</option>
  253. <option value="op97b">OP 97B</option>
  254. <option value="op97c">OP 97C</option>
  255. <option value="op97d">OP 97D</option>
  256. <option value="op98a">OP 98A</option>
  257. <option value="op98b">OP 98B</option>
  258. <option value="op98c">OP 98C</option>
  259. <option value="op98d">OP 98D</option>
  260. <option value="op99">OP 99</option>
  261. <option value="op20034">OP 2003/2004</option>
  262. <option value="op2005a">OP 2005A</option>
  263. <option value="op2005b">OP 2005B</option>
  264. <option value="op2006a">OP 2006A</option>
  265. <option value="op2006b">OP 2006B</option>
  266. <option value="op2007a">OP 2007A</option>
  267. <option value="op2007b">OP 2007B</option>
  268. <option value="op2008">OP 2008</option>
  269. <option value="nursery">Nursery</option>
  270. <option value="umum">Umum</option>
  271. </select>
  272. <label for="floatingEstate">OP Pekerja</label>
  273. </div>
  274. </div>
  275.  
  276. <div class="col-12">
  277. <div class="form-floating mb-3">
  278. <input type="text" class="form-control" id="floatingBpjs" name="bpjs" onkeyup="myFunction2()" placeholder="Masukkan Nomor BPJS" required>
  279. <label for="floatingBpjs">Nomor BPJS</label>
  280. <div class="invalid-tooltip">
  281. No BPJS Tidak Boleh Kosong!
  282. </div>
  283. </div>
  284. </div>
  285.  
  286. <div class="col-12">
  287. <div class="form-floating mb-3">
  288. <input type="text" class="form-control" id="floatingHp" name="nohp" onkeyup="myFunction3()" placeholder="Masukkan No Handphone">
  289. <label for="floatingHp">Nomor Handphone</label>
  290. <div class="invalid-tooltip">
  291. No HP Tidak Boleh Kosong!
  292. </div>
  293. </div>
  294. </div>
  295.  
  296. <div class="row mb-3 text-center">
  297. <div class="col-sm-10">
  298. <button type="submit" class="btn btn-primary">Save</button>
  299. <button type="reset" class="btn btn-secondary">Reset</button>
  300. </div>
  301.  
  302. </div>
  303.  
  304. </form>
  305. <!-- End General Form Elements -->
  306.  
  307. </div>
  308. </div>
  309. </div>
  310.  
  311. </div>
  312. </div>
  313.  
  314. </div>
  315. </div>
  316. </section>
  317.  
  318. </main><!-- End #main -->
  319.  
  320. <!-- ======= Footer ======= -->
  321. <?php include '../widgets/footer.php'; ?>
Advertisement
Add Comment
Please, Sign In to add comment
Advertisement
Public Pastes
Advertisement
We use cookies for various purposes including analytics. By continuing to use Pastebin, you agree to our use of cookies as described in the Cookies Policy.  OK, I Understand
Not a member of Pastebin yet?
Sign Up, it unlocks many cool features!