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survey.html
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<!DOCTYPE html>
<html>
<head>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="stylesheet" href="style.css">
<link rel="icon" href="icon.png">
<script src = "script.js"></script>
<title>Patient Information</title>
</head>
<body>
<div class = "top">
<h1>Cool Beans</h1>
</div>
<ul class="navBar">
<li class="navItem"><a href="index.html">Home</a></li>
<li class="navItem"><a class="active" href = "survey.html">Patient Information</a></li>
<li class="navItem"><a href="about.html">About Us</a></li>
</ul>
<div id = "homePage">
<h1>Patient Information</h1>
<form id = "form">
<h2 class = "req">* Required Fields</h2>
<div class = "starred1">
<p>
<span class = "req1">*</span>
<span class = "first">First Name: </span>
<input class = "required" type = "text" id = "first" name = "first"><br>
</div>
<div class = "starred2">
<p>
<span class = "req1">*</span>
<span class = "last">Last Name:</span>
<input class = "required" class = "required" type = "text" id = "last" name = "last"><br>
</p>
</div>
<div class = "starred3">
<p>
<span class = "req1">*</span>
<span class = "dob">Date of Birth:</span>
<input class = "required" type="date" id="dob" name="dob"><br>
</p>
</div>
<div class = "starred4">
<p>
<span class = "req1">*</span>
<span class = "gender">Gender:</span>
<select class = "required" id = "gender" name = "gender">
<option value = ""></option>
<option value = "Prefer Not to Say">Prefer Not to Say</option>
<option value = "Male">Male</option>
<option value = "Female">Female</option>
<option value = "Non-Binary">Non-Binary</option>
</select>
</p>
</div>
<div class = "starred5">
<p>
<span class = "req1">*</span>
<span class = "pid">Patient ID:</span>
<input class = "required" type="text" id="pid" name="pid"><br>
</p>
</div>
<div class = "starred6">
<p>
<span class = "req1">*</span>
<span class="address">Home Address:</label>
<input class = "required" type="text" id="address" name="address"><br>
</p>
</div>
<div class = "starred7">
<p>
<span class = "req1">*</span>
<span class="city">City</label>
<input class = "required" type="text" id="city" name="city">
</p>
</div>
<div class = starred8>
<p>
<span class = "req1">*</span>
<span class="state">State:</label>
<select class = "required" id="state" name="state" placeholder = "--SELECT--">
<option value = ""></option>
<option value = "AL">AL</option>
<option value = "AK">AK</option>
<option value = "AZ">AZ</option>
<option value = "AR">AR</option>
<option value = "CA">CA</option>
<option value = "CO">CO</option>
<option value = "CT">CT</option>
<option value = "DE">DE</option>
<option value = "FL">FL</option>
<option value = "GA">GA</option>
<option value = "HI">HI</option>
<option value = "ID">ID</option>
<option value = "IL">IL</option>
<option value = "IN">IN</option>
<option value = "IA">IA</option>
<option value = "KS">KS</option>
<option value = "KY">KY</option>
<option value = "LA">LA</option>
<option value = "ME">ME</option>
<option value = "MD">MD</option>
<option value = "MA">MA</option>
<option value = "MI">MI</option>
<option value = "MN">MN</option>
<option value = "MS">MS</option>
<option value = "MO">MO</option>
<option value = "MT">MT</option>
<option value = "NE">NE</option>
<option value = "NV">NV</option>
<option value = "NH">NH</option>
<option value = "NJ">NJ</option>
<option value = "NM">NM</option>
<option value = "NY">NY</option>
<option value = "NC">NC</option>
<option value = "ND">ND</option>
<option value = "OH">OH</option>
<option value = "OK">OK</option>
<option value = "OR">OR</option>
<option value = "PA">PA</option>
<option value = "RI">RI</option>
<option value = "SC">SC</option>
<option value = "SD">SD</option>
<option value = "TN">TN</option>
<option value = "TX">TX</option>
<option value = "UT">UT</option>
<option value = "VT">VT</option>
<option value = "VA">VA</option>
<option value = "WA">WA</option>
<option value = "WV">WV</option>
<option value = "WI">WI</option>
<option value = "WY">WY</option>
</select>
</p>
</div>
<div class = "starred9">
<p>
<span class = "req1">*</span>
<span class = "zip">Zip:</span>
<input class = "required" type = "text" id = "zip" name = "zip">
</p>
</div>
<div class = "starred10">
<p>
<span class = "req1">*</span>
<span class = "email">Email:</span>
<input class = "required" type = "email" id = "email" name = "email"><br>
</p>
</div>
<div class = "satrred11">
<p>
<span class = "req1">*</span>
<span class = "cell">Cell Phone:</label>
<input class = "required" type = "tel" id = "cell" name = "cell" placeholder="123-456-7890">
</p>
</div>
<div class = "starred12">
<p>
<span class = "req1">*</span>
<span class = "ethnicity">Ethnicity:</span>
<select class = "required" id = "ethnicity" name = "ethnicity" placeholder = "--SELECT--">
<option value = ""></option>
<option value = "Prefer Not to Say">Prefer Not to Say</option>
<option value = "Hispanic or Latino">Hispanic or Latino</option>
<option value = "Not Hispanic or Latino">Not Hispanic or Latino</option>
<option value = "Prefer Not to Say">Prefer Not to say</option>
</select>
</p>
</div>
<div class = "starred13">
<p>
<span class = "req1">*</span>
<span class="race">Race:</span>
<select class = "required" id="race" name="race" placeholder = "--SELECT--">
<option value = ""></option>
<option value="Prefer Not to Say">Prefer Not to Say</option>
<option value="American Indian or Alaska Native">
American Indian or Alaska Native</option>
<option value="Asian">Asian</option>
<option value="Black or African America">Black or African American</option>
<option value="Native Hawaiian or Other Pacific Islander">
Native Hawaiian or Other Pacific Islander</option>
<option value="White">White</option>
<option value="Prefer Not to Say">Prefer Not to Say</option>
<option value="Other">Other</option>
</select>
</p>
</div>
<div class = "starred14">
<p>
<span class = "req1">*</span>
<span class = "height">Height (in):</span>
<input class = "required" type = "number" id = "height" name = "height"><br>
</p>
</div>
<div class = "starred15">
<p>
<span class = "req1">*</span>
<span class = "weight">Weight (lbs):</span>
<input class = "required" type = "number" id = "weight" name = "weight"><br>
</p>
</div>
<label for = "notes">Notes:</label>
<div>
<textarea id = "notes" name = "notes"
rows = "20" cols = "50"></textarea>
</div>
<button onclick = "updateArray()">Submit</button>
<button onclick = "cancel()">Cancel</button>
</form>
</div>
</body>
<footer>
Created by Amelia Orodio, Juan Ospina, Jared Tjahjadi<br>
<a href="https://github.com/jeo02/jeo02.github.io.git">GitHub repository</a>
</footer>
</html>