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- <?php echo form_open('checkup/submit'); ?>
- <fieldset>
- <legend>Informasi Data Dokter</legend>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Dokter ID</label>
- <div class="col-sm-10">
- <input type="text" class="form-control" readonly>
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Nama Dokter</label>
- <div class="col-sm-10">
- <input type="text" class="form-control" readonly>
- </div>
- </div>
- </fieldset>
- <fieldset>
- <legend>Informasi Data Pasien</legend>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Pasien Id</label>
- <div class="col-sm-10">
- <div class="input-group">
- <input type="text" class="form-control">
- <div class="input-group-append">
- <button class="btn btn-outline-secondary" type="button" data-toggle="modal" data-target="#pasienModal">Browse</button>
- </div>
- </div>
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Nama Pasien</label>
- <div class="col-sm-10">
- <input type="text" readonly class="form-control">
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Alamat</label>
- <div class="col-sm-10">
- <input type="text" readonly class="form-control">
- </div>
- </div>
- </fieldset>
- <fieldset>
- <legend>Information Checkup</legend>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Tgl Checkup</label>
- <div class="col-sm-10">
- <input type="date" class="form-control">
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Keluhan</label>
- <div class="col-sm-10">
- <textarea class="form-control"></textarea>
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Diagnosa</label>
- <div class="col-sm-10">
- <textarea class="form-control"></textarea>
- </div>
- </div>
- <div class="form-group row">
- <label class="col-sm-2 col-form-label">Obat</label>
- <div class="col-sm-10">
- <div style="float:right;padding:10px;">
- <button type="button" class="btn btn-primary" data-toggle="modal" data-target="#obatModal">Add Item</button>
- <button type="button" class="btn btn-secondary">Submit Data</button>
- </div>
- <table class="table">
- <thead>
- <tr>
- <th scope="col">#</th>
- <th scope="col">ID OBAT</th>
- <th scope="col">NAMA OBAT</th>
- <th scope="col">QTY</th>
- <th scope="col">SATUAN</th>
- <th scope="col">TOTAL</th>
- </tr>
- </thead>
- <tbody>
- <tr>
- <th scope="row">
- <button type="button" class="btn btn-danger">Delete</button>
- </th>
- <td>Mark</td>
- <td>Mark</td>
- <td>Mark</td>
- <td>Mark</td>
- <td>Mark</td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- </fieldset>
- <?php echo form_close(); ?>
- <!-- Modal -->
- <div class="modal fade" id="pasienModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
- <div class="modal-dialog" role="document">
- <div class="modal-content">
- <div class="modal-header">
- <h5 class="modal-title" id="exampleModalLabel">Dialog Pencarian Pasien</h5>
- <button type="button" class="close" data-dismiss="modal" aria-label="Close">
- <span aria-hidden="true">×</span>
- </button>
- </div>
- <div class="modal-body">
- ...
- </div>
- <div class="modal-footer">
- <button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
- </div>
- </div>
- </div>
- </div>
- <!-- Modal -->
- <div class="modal fade" id="obatModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
- <div class="modal-dialog" role="document">
- <div class="modal-content">
- <div class="modal-header">
- <h5 class="modal-title" id="exampleModalLabel">Dialog Pencarian Obat</h5>
- <button type="button" class="close" data-dismiss="modal" aria-label="Close">
- <span aria-hidden="true">×</span>
- </button>
- </div>
- <div class="modal-body">
- ...
- </div>
- <div class="modal-footer">
- <button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
- </div>
- </div>
- </div>
- </div>
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