SwasthSetu/AskForHelpForm.html at main · aryandas2911/SwasthSetu · GitHub

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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>Patient Information Form</title>
    <style>
        body {
            margin: 0;
            padding: 0;
            font-family: 'Poppins', sans-serif;
            background-color: #f8f9fa;
            display: flex;
            justify-content: center;
            align-items: center;
            height: 100vh;
        }

        .form-container {
            background-color: white;
            padding: 20px;
            border-radius: 8px;
            box-shadow: 0 4px 6px rgba(0, 0, 0, 0.1);
            width: 100%;
            max-width: 500px;
        }

        h2 {
            font-size: 1.5rem;
            text-align: center;
            margin-bottom: 20px;
        }

        form {
            display: flex;
            flex-direction: column;
        }

        label {
            margin-bottom: 5px;
            font-weight: 600;
        }

        input, select, button {
            padding: 10px;
            margin-bottom: 15px;
            border: 1px solid #ccc;
            border-radius: 4px;
            font-size: 1rem;
        }

        button {
            background-color: #048581;
            color: white;
            border: none;
            cursor: pointer;
            transition: background-color 0.3s ease;
        }

        button:hover {
            background-color: #02665c;
        }
    </style>
    <script>
        document.addEventListener('DOMContentLoaded', function() {
            document.getElementById('patient-form').addEventListener('submit', function(event) {
                event.preventDefault();
                const name = document.getElementById('name').value;
                const age = document.getElementById('age').value;
                const gender = document.getElementById('gender').value;
                const contact = document.getElementById('contact').value;
                const location = document.getElementById('location').value;
                const injury = document.getElementById('injury').value;
                const transport = document.getElementById('transport').value;

                console.log(`Patient's Name: ${name}`);
                console.log(`Patient's Age: ${age}`);
                console.log(`Patient's Gender: ${gender}`);
                console.log(`Contact Number: ${contact}`);
                console.log(`Patient's Location: ${location}`);
                console.log(`Injury Type: ${injury}`);
                console.log(`Preferred Mode of Transport: ${transport}`);

                alert('Form submitted successfully!');
            });
        });
    </script>
</head>
<body>
    <div class="form-container">
        <h2>Patient Information Form</h2>
        <form id="patient-form">
            <label for="name">Patient's Name:</label>
            <input type="text" id="name" name="name" required>

            <label for="age">Patient's Age:</label>
            <input type="number" id="age" name="age" required>

            <label for="gender">Patient's Gender:</label>
            <select id="gender" name="gender" required>
                <option value="male">Male</option>
                <option value="female">Female</option>
                <option value="other">Other</option>
            </select>

            <label for="contact">Contact Number:</label>
            <input type="tel" id="contact" name="contact" required>

            <label for="location">Patient's Location:</label>
            <input type="text" id="location" name="location" required>

            <label for="injury">Injury Type:</label>
            <input type="text" id="injury" name="injury" required>

            <label for="transport">Preferred Mode of Transport:</label>
            <select id="transport" name="transport" required>
                <option value="2-wheeler">2 Wheeler</option>
                <option value="4-wheeler">4 Wheeler</option>
            </select>

            <button type="submit">Submit</button>
        </form>
    </div>
</body>
</html>