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selfassesment.html
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selfassesment.html
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<!DOCTYPE html>
<html >
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1, minimum-scale=1">
<link rel="shortcut icon" href="assets/images/favicon-1.svg" type="image/x-icon">
<meta name="description" content="">
<title>Self-Assessment - Curec</title>
<link rel="stylesheet" href="assets/Material-Design-Icons/css/material.css">
<link rel="stylesheet" href="assets/FontAwesome/css/font-awesome.css">
<link rel="stylesheet" href="assets/tether/tether.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap.min.css">
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<link rel="stylesheet" href="assets/bootstrap/css/bootstrap-reboot.min.css">
<link rel="stylesheet" href="assets/dropdown/css/style.css">
<link rel="stylesheet" href="assets/formstyler/jquery.formstyler.css">
<link rel="stylesheet" href="assets/formstyler/jquery.formstyler.theme.css">
<link rel="stylesheet" href="assets/datepicker/jquery.datetimepicker.min.css">
<link rel="stylesheet" href="assets/socicon/css/styles.css">
<link rel="stylesheet" href="assets/theme/css/style.css">
<link rel="preload" href="https://fonts.googleapis.com/css?family=Muli:200,200i,300,300i,400,400i,500,500i,600,600i,700,700i,800,800i,900,900i&display=swap" as="style" onload="this.onload=null;this.rel='stylesheet'">
<noscript><link rel="stylesheet" href="https://fonts.googleapis.com/css?family=Muli:200,200i,300,300i,400,400i,500,500i,600,600i,700,700i,800,800i,900,900i&display=swap"></noscript>
<link rel="preload" as="style" href="assets/mobirise/css/mbr-additional.css"><link rel="stylesheet" href="assets/mobirise/css/mbr-additional.css" type="text/css">
<script src="./access/doctor/system/js/healthAPI.js"></script>
<meta name="theme-color" content="#4f87fb">
<link rel="manifest" href="manifest.json">
<script src="sw-connect.js"></script>
<meta name="apple-mobile-web-app-capable" content="yes">
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<link rel="apple-touch-startup-image" media="(device-width: 375px) and (device-height: 667px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-750x1334.png">
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<link rel="apple-touch-startup-image" media="(device-width: 768px) and (device-height: 1024px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-1536x2048.png">
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<link rel="apple-touch-startup-image" media="(device-width: 1024px) and (device-height: 1366px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-2048x2732.png">
<meta name="apple-mobile-web-app-status-bar-style" content="default">
<meta name="apple-mobile-web-app-title" content="CuRec">
<link rel="apple-touch-icon" href="apple-touch-icon.png">
</head>
<body>
<section class="menu01 cid-sH04QkaHZV" once="menu" id="menu1-0">
<nav class="navbar navbar-dropdown beta-menu align-items-center navbar-fixed-top navbar-toggleable-sm bg-color transparent">
<div class="menu-bottom order-0 order-lg-1">
<div class="menu-logo">
<div class="navbar-brand">
<span class="navbar-logo">
<a href="index.html">
<img src="assets/images/logo-121x57.png" alt="CuRec" style="height: 3.8rem;">
</a>
</span>
</div>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#navbarSupportedContent, #topLine" aria-controls="navbarSupportedContent" aria-expanded="false" aria-label="Toggle navigation">
<div class="hamburger">
<span></span>
<span></span>
<span></span>
<span></span>
</div>
</button>
</div>
<div class="collapse navbar-collapse" id="navbarSupportedContent">
<ul class="navbar-nav nav-dropdown js-float-line" data-app-modern-menu="true"><li class="nav-item">
<a class="nav-link link mbr-black text-secondary text-primary display-4" href="index.html">
Home
</a>
</li>
<li class="nav-item">
<a class="nav-link link mbr-black text-secondary text-primary display-4" href="index.html#info1-1u">
Contact Us
</a>
</li></ul>
<div class="navbar-buttons mbr-section-btn"><a class="btn btn-md btn-primary-outline display-4" href="signin.html">SIGN IN</a></div>
</div>
</div>
</nav>
</section>
<section class="header1 cid-sHb4AUNHM8" id="header10-1p">
<svg class="svg1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" width="1380px" height="810px" viewBox="0 0 1380 810" preserveAspectRatio="xMidYMid meet">
<rect id="svgEditorBackground" x="0" y="0" width="1380" height="810" style="fill: none; stroke: none;"></rect>
<circle id="e1_circle" cx="309" cy="433" style="fill:aqua;stroke:black;stroke-width:0px;" r="149.486"></circle>
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</circle>
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</svg>
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<div class="container">
<div class="row justify-content-md-center">
<div class="col-md-10 align-center">
</div>
</div>
</div>
</section>
<section class="form2 cid-sH1cyqNr2A" id="form02-13">
<div class="container">
<div class="row">
<div class="col-lg-12 mx-auto mbr-form">
<!--Formbuilder Form-->
<form action="./access/dbClass.php" method="POST" class="mbr-form form-with-styler">
<div class="form-row">
<div hidden="hidden" data-form-alert-danger="" class="alert alert-danger col-12">Oops...! some problem!</div>
</div>
<div class="dragArea form-row">
<div class="col-lg-12 col-md-12 col-sm-12">
<h4 class="align-left mbr-fonts-style display-5">Please answer the questions asked to asses yourself..</h4>
</div>
<div class="col-lg-12 col-md-12 col-sm-12 form-group" data-for="text">
<input type="text" name="text" placeholder="Name" data-form-field="text" class="form-control display-7" value="" id="text-form02-13">
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<p class="mbr-fonts-style display-7">
</p>
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<h5 class="mbr-fonts-style display-5">Basic Symptoms</h5>
</div>
<div data-for="fever" class="col-lg-3 col-md-12 col-sm-12 form-group">
<label for="fever-form02-13" class="form-control-label mbr-fonts-style display-7">Fever</label>
<select name="fever" data-form-field="fever" class="form-control display-7" id="fever-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="cough" class="col-lg-3 col-md-12 col-sm-12 form-group">
<label for="cough-form02-13" class="form-control-label mbr-fonts-style display-7">Cough</label>
<select name="cough" data-form-field="cough" class="form-control display-7" id="cough-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div class="col-lg-3 col-md-12 col-sm-12 form-group" data-for="sorethroat">
<label for="sorethroat-form02-13" class="form-control-label mbr-fonts-style display-7">Sore Throat</label>
<select name="sorethroat" data-form-field="sorethroat" class="form-control display-7" id="sorethroat-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="cold" class="col-lg-3 col-md-12 col-sm-12 form-group">
<label for="cold-form02-13" class="form-control-label mbr-fonts-style display-7">Cold</label>
<select name="cold" data-form-field="cold" class="form-control display-7" id="cold-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="difficultyinbreathing" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="difficultyinbreathing-form02-13" class="form-control-label mbr-fonts-style display-7">Difficulty in Breathing</label>
<select name="difficultyinbreathing" data-form-field="difficultyinbreathing" class="form-control display-7" id="difficultyinbreathing-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="bodyaches" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="bodyaches-form02-13" class="form-control-label mbr-fonts-style display-7">Body Aches & Pain</label>
<select name="bodyaches" data-form-field="bodyaches" class="form-control display-7" id="bodyaches-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="lossofsmell" class="col-lg-4 col-md-12 col-sm-12 form-group">
<label for="lossofsmell-form02-13" class="form-control-label mbr-fonts-style display-7">Loss of Smell</label>
<select name="lossofsmell" data-form-field="lossofsmell" class="form-control display-7" id="lossofsmell-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="diarrhoea" class="col-lg-4 col-md-12 col-sm-12 form-group">
<label for="diarrhoea-form02-13" class="form-control-label mbr-fonts-style display-7">Diarrhoea</label>
<select name="diarrhoea" data-form-field="diarrhoea" class="form-control display-7" id="diarrhoea-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="urineoutput" class="col-lg-4 col-md-12 col-sm-12 form-group">
<label for="urineoutput-form02-13" class="form-control-label mbr-fonts-style display-7">Urine Output</label>
<select name="urineoutput" data-form-field="urineoutput" class="form-control display-7" id="urineoutput-form02-13">
<option value="Normal">Normal</option>
<option value="Reduced">Reduced</option>
</select>
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<p class="mbr-fonts-style display-7">
</p>
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<h5 class="mbr-fonts-style display-5">Consider the time period 14 days prior to filling this section</h5>
</div>
<div data-for="travelabroad" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="travelabroad-form02-13" class="form-control-label mbr-fonts-style display-7">Did you traveled abroad?</label>
<select name="travelabroad" data-form-field="travelabroad" class="form-control display-7" id="travelabroad-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="traveldate" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="traveldate-form02-13" class="form-control-label mbr-fonts-style display-7">If Yes, Date of Return</label>
<input type="date" name="traveldate" data-form-field="traveldate" class="form-control display-7" value="2018-07-22" id="traveldate-form02-13">
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<h6 class="mbr-fonts-style display-5">Have you come in contact with..</h6>
</div>
<div data-for="covid19patient" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="covid19patient-form02-13" class="form-control-label mbr-fonts-style display-7">A COVID-19 patient/ A patient suspected to have COVID-19</label>
<select name="covid19patient" data-form-field="covid19patient" class="form-control display-7" id="covid19patient-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="comefromabroad" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="comefromabroad-form02-13" class="form-control-label mbr-fonts-style display-7">A person who came from abroad</label>
<select name="comefromabroad" data-form-field="comefromabroad" class="form-control display-7" id="comefromabroad-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="livinginriskarea" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="livinginriskarea-form02-13" class="form-control-label mbr-fonts-style display-7">A person living in a high risk area</label>
<select name="livinginriskarea" data-form-field="livinginriskarea" class="form-control display-7" id="livinginriskarea-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="directedquarantinecamp" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="directedquarantinecamp-form02-13" class="form-control-label mbr-fonts-style display-7">A person directed to a quarantine camp</label>
<select name="directedquarantinecamp" data-form-field="directedquarantinecamp" class="form-control display-7" id="directedquarantinecamp-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="employedinquarantinecamp" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="employedinquarantinecamp-form02-13" class="form-control-label mbr-fonts-style display-7">A person employed in a quarantine camp, tourism industry, Airport or Harbour</label>
<select name="employedinquarantinecamp" data-form-field="employedinquarantinecamp" class="form-control display-7" id="employedinquarantinecamp-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<p class="mbr-fonts-style display-7">
</p>
</div>
<div class="col-lg-12 col-md-12 col-sm-12">
<h5 class="mbr-fonts-style display-5">We're almost done...</h5>
</div>
<div data-for="heartdisease" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="heartdisease-form02-13" class="form-control-label mbr-fonts-style display-7">Heart Diseases</label>
<select name="heartdisease" data-form-field="heartdisease" class="form-control display-7" id="heartdisease-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="bloodpressure" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="bloodpressure-form02-13" class="form-control-label mbr-fonts-style display-7">High Blood Pressure</label>
<select name="bloodpressure" data-form-field="bloodpressure" class="form-control display-7" id="bloodpressure-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="diabetes" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="diabetes-form02-13" class="form-control-label mbr-fonts-style display-7">Diabetes</label>
<select name="diabetes" data-form-field="diabetes" class="form-control display-7" id="diabetes-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="lungdisease" class="col-lg-6 col-md-12 col-sm-12 form-group">
<label for="lungdisease-form02-13" class="form-control-label mbr-fonts-style display-7">Lung Diseases</label>
<select name="lungdisease" data-form-field="lungdisease" class="form-control display-7" id="lungdisease-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div data-for="otherdiseases" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="otherdiseases-form02-13" class="form-control-label mbr-fonts-style display-7">Other Diseases</label>
<select name="otherdiseases" data-form-field="otherdiseases" class="form-control display-7" id="otherdiseases-form02-13">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
<div class="col-auto">
<button type="submit" class="btn btn-warning display-4" name="assess">SUBMIT</button>
</div>
</div>
</form><!--Formbuilder Form-->
</div>
</div>
</div>
</section>
<section class="footer1 audiom4_footer1 cid-sHiy402oi2 mbr-reveal" once="footers" id="footer1-1z">
<div class="container">
<div class="media-container-row align-center mbr-white">
<div class="row title-row">
<h1 class="mbr-section-title align-center mbr-bold pb-1 mbr-fonts-style display-5">
Curec</h1>
</div>
<div class="row social-row">
<div class="social-list align-right pb-2">
<div class="soc-item">
<a href="https://twitter.com/mobirise" target="_blank">
<span class="socicon-twitter socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div><div class="soc-item">
<a href="https://www.facebook.com/pages/Mobirise/1616226671953247" target="_blank">
<span class="socicon-facebook socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div><div class="soc-item">
<a href="https://www.youtube.com/c/mobirise" target="_blank">
<span class="socicon-youtube socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div></div>
</div>
<div class="row row-links">
<ul class="foot-menu">
<li class="foot-menu-item mbr-fonts-style display-4">+9411 263 5268</li><li class="foot-menu-item mbr-fonts-style display-4">
info@curec.life
</li><li class="foot-menu-item mbr-fonts-style display-4">Ratmalana, Sri Lanka</li></ul>
</div>
<div class="row row-copirayt">
<p class="mbr-text mb-0 mbr-fonts-style mbr-white align-center display-4">
© Copyright 2021 <a href="https://www.kdu.ac.lk" class="text-primary">Kotelawala Defence Univerisity</a> - All Rights Reserved
</p>
</div>
</div>
</div>
</section>
<script src="assets/web/assets/jquery/jquery.min.js"></script>
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