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patient details.html
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patient details.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Registration Page</title>
<style>
body {
font-family: Arial, sans-serif;
margin: 0;
padding: 0;
}
nav {
background-color: #264488;
overflow: hidden;
padding: 10px 0;
}
nav ul {
list-style-type: none;
margin: 0;
padding: 0;
text-align: center;
}
nav ul li {
display: inline;
}
nav ul li a {
display: inline-block;
color: white;
padding: 14px 20px;
text-decoration: none;
}
nav ul li a:hover {
background-color: #264488;
}
section {
margin: 20px;
}
h2 {
color: #264488;
}
form {
margin-top: 10px;
}
label {
display: inline-block;
width: 150px;
}
input[type="text"],
input[type="date"],
input[type="file"],
select {
width: 300px;
padding: 8px;
margin: 5px 0;
display: inline-block;
border: 1px solid #ccc;
border-radius: 4px;
box-sizing: border-box;
}
input[type="submit"] {
background-color: #264488;
color: white;
padding: 10px 20px;
border: none;
border-radius: 4px;
cursor: pointer;
}
input[type="submit"]:hover {
background-color: #264488;
}
.required {
color: red;
}
</style>
</head>
<body>
<!-- Navbar -->
<nav>
<ul>
<li><a href="#patient_details"><h1>Registration</h1></a></li>
<!-- <li><a href="#doctor_details">Doctor Details</a></li>
<li><a href="#contact_details">Contact Details</a></li> -->
</ul>
</nav>
<!-- Patient Personal Details -->
<section id="patient_details">
<h2>Patient Personal Details</h2>
<form id="registrationForm" action="process_registration.php" method="post">
<label for="title">Title:</label><span class="required">*</span>
<select name="title" id="title">
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
</select>
<br>
<label for="first_name">First Name:</label><span class="required">*</span>
<input type="text" id="first_name" name="first_name" required>
<label for="middle_name">Middle Name:</label><span class="required">*</span>
<!-- <input type="text" id="first_name" name="first_name" required> -->
<input type="text" id="middle_name" name="middle_name">
<label for="last_name">Last Name:</label><span class="required">*</span>
<input type="text" id="last_name" name="last_name" required>
<br>
<label for="dob">Date of Birth:</label><span class="required">*</span>
<input type="date" id="dob" name="dob" required>
<br>
<label for="gender">Gender:</label><span class="required">*</span>
<input type="radio" id="male" name="gender" value="male" required>
<label for="male">Male</label>
<input type="radio" id="female" name="gender" value="female">
<label for="female">Female</label>
<input type="radio" id="other" name="gender" value="other">
<label for="other">Other</label>
<br>
<label for="address1">Address 1:</label><span class="required">*</span>
<input type="text" id="address1" name="address1" required>
<br>
<label for="address2">Address 2:</label>
<input type="text" id="address2" name="address2">
<br>
<label for="passport_number">Passport Number:</label><span class="required">*</span>
<input type="text" id="passport_number" name="passport_number" required>
<br>
<label for="photo">Upload Your Photo:</label><span class="required">*</span>
<input type="file" id="photo" name="photo">
<br>
<input type="submit" value="Save">
</form>
</section>
<!-- Automatic ID Generator -->
<script>
// Function to generate a 12-digit ID with passport number
function generateID(passportNumber) {
var id = passportNumber.replace(/\D/g,''); // Extract only digits from passport number
id = id.padEnd(12, '0'); // Pad with zeros if passport number is shorter than 12 digits
return id;
}
// Function to handle form submission
function handleSubmit(event) {
event.preventDefault(); // Prevent form submission
// Get passport number from the form
var passportNumber = document.getElementById("passport_number").value;
// Generate ID
var generatedID = generateID(passportNumber);
// Display generated ID
console.log("Generated ID:", generatedID);
alert("Generated ID: " + generatedID);
// Optionally, you can submit the form here
// document.getElementById("registrationForm").submit();
}
// Add event listener to form submission
document.getElementById("registrationForm").addEventListener("submit", handleSubmit);
</script>
</body>
</html>