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Sagarvd01

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Sagarvd01
Mar 30th, 2017
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  1. <!DOCTYPE html>
  2. <html lang="en-US">
  3. <meta charset="UTF-8">
  4. <head>
  5. <title>Medical Form</title>
  6. <link rel="stylesheet" type="text/css" href="RegoForm.css">
  7. </head>
  8. <body>
  9. <form action="link to where it needs to go" method="post" name="medicalform" onsubmit="return validate();">
  10. <fieldset>
  11. <legend>Personal information:</legend>
  12. Title:
  13. <label for="mr">Mr.</label>
  14. <input type="radio" name="title" id="mr" value="mr" onclick="titleRadioChanged(this)">
  15. <label for="mrs">Mrs.</label>
  16. <input type="radio" name="title" id="mrs" value="mrs" onclick="titleRadioChanged(this)">
  17. <label for="miss">Miss</label>
  18. <input type="radio" name="title" id="miss" value="miss" onclick="titleRadioChanged(this)">
  19. <label for="ms">Ms.</label>
  20. <input type="radio" name="title" id="ms" value="ms" onclick="titleRadioChanged(this)">
  21. <label for="other">Other:</label>
  22. <input type="radio" name="title" id="other" value="other" onclick="titleRadioChanged(this)">
  23. <input type="text" name="title" id="titleinputtext" disabled>
  24. <hr>
  25.  
  26. Surname: <input type="text" name="surname"><hr>
  27. Given Name(s) in Full:<input type="text" name="givennames"><hr>
  28. Previous Surname(s) (if applicable): <input type="text" name="previoussurname"><hr>
  29. Date of Birth: <input type="date" name="dob" min="1900-01-01"><hr>
  30. Sex: <label for="male">Male</label>
  31. <input type="radio" id="male" name="sex" value="male">
  32. <label for="female">Female</label>
  33. <input type="radio" id="female" name="sex" value="female"><hr>
  34. Country of Birth: <input type="text" name="cob"><br>
  35. If Australia, what state:<input type="text" name="sob">
  36.  
  37.  
  38. <hr>
  39. Marital Status:
  40. <pre>
  41. <label for="married">Married</label><input type="radio" name="marital" id="married" value="married"> <label for="seperated">Seperated</label><input type="radio" id="seperated" name="marital" value="seperated">
  42. <label for="single">Single</label><input type="radio" name="marital" id="single" value="single"> <label for="defacto">De Facto</label><input type="radio" id="defacto" name="marital" value="defacto">
  43. <label for="widowed">Widowed</label><input type="radio" name="marital" id="widowed" value="widowed"> <label for="divorced">Divorced</label><input type="radio" id="divorced" name="marital" value="divorced">
  44. </pre>
  45. <hr>
  46. Do you wish to be visited by a Church Representative?
  47. <label for="churchyes">Yes</label> <input type="radio" id="churchyes" name="church" value="churchyes">
  48. <label for="churchno">No</label><input type="radio" id="churchno" name="church" value="churchno">
  49. <hr>
  50. Aboriginal/Torres Straight Islander: <label for="minorityyes">Yes<input type="radio" id="minorityyes" name="minority" value="minority">
  51. <label for="minorityno">No<input type="radio" id="minorityno" name="minority" value="minorityno">
  52. <hr>
  53. Address: <input type="text" name="address">
  54. <hr>
  55. Postcode: <input type="text" name="postcode">
  56. <hr>
  57. Phone No: Home <input type="text" name="homenum">
  58. Mobile <input type="text" name="mobilenum">
  59. <br>
  60. </fieldset>
  61. <br>
  62. <fieldset>
  63. <h2> Next of Kin / Contact Person </h2>
  64. <hr>
  65. Name: <input type="text" name="nokname">
  66. <hr>
  67. Address: <input type="text" name="nokaddress">
  68. <hr>
  69. Home No. : <input type="text" name="nokhomenum">
  70. <hr>
  71. Mobile No. : <input type="text" name="nokmobilenum">
  72. <hr>
  73. Relationship to Patient: <input type="text" name="nokrelationship">
  74. <hr>
  75. Medicare No:<input type="text" name="medicarenum">
  76. Card ID No:<input type="text" name="medicareidnum">
  77. Expiry Date:<input type="date" name="medicareexpiry">
  78. </fieldset>
  79. <br>
  80. <fieldset>
  81. <h2> Other Details </h2>
  82. Name of your GP: <input type="text" name="gpname">
  83. <hr>
  84. Have you been a patient in this Hospital or had pathology/x-rays done here?
  85. <br>
  86. <label for="expatientyes">Yes<input type="radio" id="expatientyes" name="expatient" value="expatientyes">
  87. <br>
  88. <label for="expatientno">No<input type="radio" id="expatientno" name="expatient" value="expatientno">
  89. <hr>
  90. Do you have private health insurance? <br>
  91. <label for="insuranceyes">Yes<input type="radio" id="insuranceyes" name="insurance" value="insuranceyes">
  92. <br>
  93. <label for="insuranceno">No<input type="radio" id="insuranceno" name="insurance" value="insuranceno">
  94. </fieldset>
  95. <br>
  96. <fieldset>
  97. <h2>Health Insurance Details</h2>
  98. Name of Fund: <input type="text" name="insurancename"> <hr>
  99. Membership No: <input type="text" name="insurancenum"> <hr>
  100. Level of Insurance:
  101. <pre>
  102. <label for="insuranceleveltop">Top<input type="radio" id="insuranceleveltop" name="insurancelevel" value="insuranceleveltop"><label for="insurancelevelintermediate">Intermediate<input type="radio" id="insurancelevelintermediate" name="insurancelevel" value="insurancelevelintermediate">
  103. <label for="insurancelevelbasic">Basic<input type="radio" id="insurancelevelbasic" name="insurancelevel" value="insurancelevelbasic"> <label for="insurancelevelextrasonly">Extras Only<input type="radio" id="insurancelevelextrasonly" name="insurancelevel" value="insurancelevelextrasonly">
  104. </pre>
  105. <hr>
  106. Does an excess apply? <br>
  107. <label for="excessyes">Yes<input type="radio" id="excessyes"name="excess" value="excessyes" onclick="excessRadioChanged(this)"> <br>
  108. <label for="excessno">No<input type="radio" id="excessno" name="excess" value="excessno" onclick="excessRadioChanged(this)"> <br>
  109. Excess amount ($): <input type="text" id="excessinputtext" name="excessamount" disabled>
  110. </fieldset>
  111. <br>
  112. <fieldset>
  113. <h2> WorkCare / TAC / Workers Comp. </h2>
  114. <br>
  115. Approval must be obtained prior to admission. Correspondence verifying liability must be presented on admission. <hr>
  116. Date of Injury/Accident: <input type="date" name="injurydate"> <hr>
  117. Phone No.: <input type="text" name="workcarenum"> <hr>
  118. Insurance Company: <input type="text" name="insurancecompany"> <hr>
  119. Claim No: <input type="text" name="claimnum"> <hr>
  120. Your solicitor: <input type="text" name="solicitor"> <hr>
  121. Address: <input type="text" name="workcareaddress"> <hr>
  122. Phone No.: <input type="text" name="solicitorphone"> <hr>
  123. If WorkCare / Workers Comp. : <br>
  124. <label for="iscare">WorkCare <input type="radio" id="iscare" name="workcareorcomp" value="iscare"> <br>
  125. <label for="iscomp">Workers Comp. <input type="radio" id="iscomp" name="workcareorcomp" value="iscomp"> <hr>
  126. Employer: <input type="text" name="employer"><br>
  127. Address: <input type="text" name="employeraddress"> <hr>
  128. <br>
  129. <br>
  130. </fieldset>
  131. <br>
  132. <br>
  133. <input type="submit" value="Submit" id="submit" onfocus="myFunction()">
  134. <br>
  135. <hr>
  136. <footer>
  137. <h4> Private Insurance </h4>
  138. If you elect to be a private patient, the Hospital will claim bed fees on your behalf. Please bring your membership book at time of admission.
  139. </footer>
  140. </form>
  141. <script src="script.js"></script>
  142. <script>
  143. yeahbaby();
  144. </script>
  145. </body>
  146. </html>
  147.  
  148.  
  149. and here is my javascript file (please ignore the shitty code underneath the yeahbaby(); function hahaha)
  150.  
  151. function yeahbaby() {
  152. document.getElementsByName("surname")[0].setAttribute("maxLength", "40");
  153. }
  154. function validate(){
  155. if(document.medicalform.title.value == "")
  156. {
  157. alert("Please choose your preferred title.");
  158. return false;
  159. }
  160. else{
  161. if(document.medicalform.surname.value == "")
  162. {
  163. alert("Please enter surname");
  164. return false;
  165. }
  166. else{
  167. if(document.medicalform.givennames.value == "")
  168. {
  169. alert("Please enter given name");
  170. return false;
  171. }
  172. else{
  173. if(document.medicalform.dob.value == "")
  174. {
  175. alert("Please enter your date of birth");
  176. return false;
  177. }
  178. else{
  179. if(document.medicalform.address.value == "")
  180. {
  181. alert("Please enter your address");
  182. return false;
  183. }
  184. else{
  185. if(document.medicalform.postcode.value == "")
  186. {
  187. alert("Please enter your postcode");
  188. return false;
  189. }
  190. else{
  191. if(document.medicalform.homenum.value == "" && document.medicalform.mobilenum.value == "")
  192. {
  193. alert("Please enter at least one phone number");
  194. return false;
  195. }
  196. else{
  197. if(document.medicalform.medicarenum.value == "")
  198. {
  199. alert("Please enter your medicare number");
  200. return false;
  201. }
  202. else{
  203. if(document.medicalform.medicareidnum.value == "")
  204. {
  205. alert("Please enter your medicare card number");
  206. return false;
  207. }
  208. else{
  209. if(document.medicalform.medicareexpiry.value == "")
  210. {
  211. alert("Please enter medicare card expiry date");
  212. return false;
  213. }
  214. else{
  215.  
  216. if(document.medicalform.insurancename.value == "")
  217. {
  218. alert("Please enter your insurance company's name");
  219. return false;
  220. }
  221. else{
  222. if(document.medicalform.insurancenum.value == "")
  223. {
  224. alert("Please enter your insurance number");
  225. return false;
  226. }
  227. else{
  228. if(document.medicalform.insurancecompany.value == "")
  229. {
  230. alert("Please enter please enter your insurance company (idk)");
  231. return false;
  232. }
  233. else{
  234. if(document.medicalform.claimnum.value == "")
  235. {
  236. alert("Please enter your claim number");
  237. return false;
  238. }
  239. else{
  240. return true;
  241. }
  242. }}}}}}}}}}}}}}
  243. function excessRadioChanged(element) {
  244. document.getElementById('excessinputtext').disabled = element.value != 'excessyes';}
  245. function titleRadioChanged(element) {
  246. document.getElementById('titleinputtext').disabled = element.value != 'other';}
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