<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<title>Submit</title>
<style>
body { font-family: Arial; padding: 20px; background: #f2f2f2; }
form { background: #fff; padding: 20px; border-radius: 8px; max-width: 800px; margin: auto; }
h2 { text-align: center; }
label { display: block; margin-top: 15px; }
input, select, textarea { width: 100%; padding: 8px; margin-top: 5px; }
button { margin-top: 20px; padding: 10px 20px; background: #28a745; color: white; border: none; border-radius: 4px; cursor: pointer; }
button:hover { background: #218838; }
</style>
</head>
<body>
<form action="submit_form.php" method="POST">
<h2>Patient Admission Form</h2>
<!-- Patient Info -->
<label for="sex">Sex:</label>
<select name="sex" id="sex" required>
<option value="">Select</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Other">Other</option>
</select>
<label for="birth_date">Birth Date:</label>
<input type="date" name="birth_date" id="birth_date" required>
<!-- Admission Info -->
<label for="admission_date">Admission Date:</label>
<input type="date" name="admission_date" id="admission_date" required>
<label for="service">Service:</label>
<select name="service" id="service" required>
<option value="">Select</option>
<option value="Medicine">Medicine</option>
<option value="Pediatrics">Pediatrics</option>
<option value="Obstetrics-Gynecology">Obstetrics-Gynecology</option>
<option value="Surgery">Surgery</option>
</select>
<label for="ward_type">Ward Type:</label>
<select name="ward_type" id="ward_type" required>
<option value="Charity">Charity</option>
<option value="Private">Private</option>
</select>
<!-- Initial Notes -->
<label for="chief_complaint">Chief Complaint:</label>
<textarea name="chief_complaint" id="chief_complaint"></textarea>
<label for="history_present_illness">History of Present Illness:</label>
<textarea name="history_present_illness" id="history_present_illness"></textarea>
<!-- Lab Result -->
<label for="lab_test_name">Lab Test Name:</label>
<input type="text" name="lab_test_name" id="lab_test_name">
<label for="lab_value">Lab Value:</label>
<input type="text" name="lab_value" id="lab_value">
<label for="units">Units:</label>
<input type="text" name="units" id="units">
<label for="normal_range">Normal Range:</label>
<input type="text" name="normal_range" id="normal_range">
<label for="lab_source">Source:</label>
<select name="lab_source" id="lab_source">
<option value="In-Hospital">In-Hospital</option>
<option value="External">External</option>
</select>
<label for="date_collected">Date Collected:</label>
<input type="date" name="date_collected" id="date_collected">
<button type="submit">Submit</button>
</form>
</body>
</html>