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Brestcancer_Form.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>Brest Cancer Patient Information Form</title>
<!-- Bootstrap CSS -->
<link href="https://maxcdn.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css" rel="stylesheet">
<link href="Breastcancer_Form.css" rel="stylesheet">
<script src="Breastcancer_Form.js"></script>
</head>
<body>
<div class="container mt-5">
<h2>Brest Cancer Patient Information Form</h2>
<input id="Autofill_Button" class="btn btn-primary" type="button" value="Autofill" onclick="Autofill()">
<form>
<!-- Personal Information -->
<div class="form-group">
<label for="name">Name:</label>
<input type="text" class="form-control" id="name" placeholder="Enter name">
</div>
<div class="form-group">
<label for="age">Age:</label>
<input type="text" class="form-control" id="age" placeholder="Enter age">
</div>
<div class="form-group">
<label for="dob">Date of Birth:</label>
<input type="date" class="form-control" id="dob">
</div>
<div class="form-group">
<label>Gender:</label>
<div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="male" value="Male">
<label class="form-check-label" for="male">Male</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="female" value="Female">
<label class="form-check-label" for="female">Female</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="other" value="Other">
<label class="form-check-label" for="other">Other</label>
</div>
</div>
</div>
<div class="form-group">
<label for="bloodGroup">Blood Group:</label>
<select class="form-control" id="bloodGroup">
<option value="1">A+</option>
<option value="2">A-</option>
<option value="3">B+</option>
<option value="4">B-</option>
<option value="5">O+</option>
<option value="6">O-</option>
<option value="7">AB+</option>
<option value="8">AB-</option>
</select>
</div>
<div class="form-group">
<label for="height">Height (cm):</label>
<input type="text" class="form-control" id="height" placeholder="Enter height">
</div>
<div class="form-group">
<label for="weight">Weight (kg):</label>
<input type="text" class="form-control" id="weight" placeholder="Enter weight">
</div>
<div class="form-group">
<label for="diagnosis">Diagnosis:</label>
<input type="text" class="form-control" id="diagnosis" placeholder="Enter diagnosis">
</div>
<div class="form-group">
<label for="followUpDate">Follow-up Date:</label>
<input type="date" class="form-control" id="followUpDate">
</div>
<div class="form-group">
<label for="operationDate">Operation Date:</label>
<input type="date" class="form-control" id="operationDate">
</div>
<div class="form-group">
<label>Medical History:</label>
<div class="form-check">
<input type="checkbox" class="form-check-input" id="breastLump">
<label class="form-check-label" for="breastLump">Breast Lump Discovered</label>
</div>
<div class="form-check">
<input type="checkbox" class="form-check-input" id="previousHistory">
<label class="form-check-label" for="previousHistory">Previous history of fractures</label>
</div>
<div class="form-check">
<input type="checkbox" class="form-check-input" id="familyHistory">
<label class="form-check-label" for="familyHistory">Family history of bone disorders</label>
</div>
<div class="form-group">
<label for="otherMedicalHistory">Other:</label>
<input type="text" class="form-control" id="otherMedicalHistory" placeholder="Enter other medical history">
</div>
</div>
<div class="form-group">
<label for="additionalComments">Additional Comments:</label>
<textarea class="form-control" id="additionalComments" rows="3"></textarea>
</div>
<!-- Hospital Information -->
<h3>Hospital Information</h3>
<div class="form-group">
<label for="hospitalName">Hospital Name:</label>
<input type="text" class="form-control" id="hospitalName" placeholder="Enter hospital name">
</div>
<div class="form-group">
<label for="hospitalAddress">Hospital Address:</label>
<textarea class="form-control" id="hospitalAddress" rows="3"
placeholder="Enter hospital address"></textarea>
</div>
<div class="form-group">
<label for="doctorName">Doctor Name:</label>
<input type="text" class="form-control" id="doctorName" placeholder="Enter doctor's name">
</div>
<div class="form-group">
<label for="doctorSpecialization">Doctor Specialization:</label>
<input type="text" class="form-control" id="doctorSpecialization"
placeholder="Enter doctor's specialization">
</div>
<!-- Medication Plan -->
<h3>Medication Plan</h3>
<div class="form-group">
<label for="medicationName1">Medication Name:</label>
<input type="text" class="form-control" id="medicationName1" placeholder="Enter medication name">
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="dosage1">Dosage (mg):</label>
<input type="text" class="form-control" id="dosage1" placeholder="Enter dosage">
</div>
<div class="form-group col-md-4">
<label for="frequency1">Frequency:</label>
<input type="text" class="form-control" id="frequency1" placeholder="Enter frequency">
</div>
<div class="form-group col-md-4">
<label for="startDate1">Start Date:</label>
<input type="date" class="form-control" id="startDate1">
</div>
<div class="form-group col-md-4">
<label for="endDate1">End Date:</label>
<input type="date" class="form-control" id="endDate1">
</div>
</div>
<div class="form-group">
<label for="medicationName2">Medication Name:</label>
<input type="text" class="form-control" id="medicationName2" placeholder="Enter medication name">
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="dosage2">Dosage (mg):</label>
<input type="text" class="form-control" id="dosage2" placeholder="Enter dosage">
</div>
<div class="form-group col-md-4">
<label for="frequency2">Frequency:</label>
<input type="text" class="form-control" id="frequency2" placeholder="Enter frequency">
</div>
<div class="form-group col-md-4">
<label for="startDate2">Start Date:</label>
<input type="date" class="form-control" id="startDate2">
</div>
<div class="form-group col-md-4">
<label for="endDate2">End Date:</label>
<input type="date" class="form-control" id="endDate2">
</div>
</div>
<div class="form-group">
<label for="medicationName3">Medication Name:</label>
<input type="text" class="form-control" id="medicationName3" placeholder="Enter medication name">
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="dosage2">Dosage (mg):</label>
<input type="text" class="form-control" id="dosage3" placeholder="Enter dosage">
</div>
<div class="form-group col-md-4">
<label for="frequency2">Frequency:</label>
<input type="text" class="form-control" id="frequency3" placeholder="Enter frequency">
</div>
<div class="form-group col-md-4">
<label for="startDate2">Start Date:</label>
<input type="date" class="form-control" id="startDate3">
</div>
<div class="form-group col-md-4">
<label for="endDate2">End Date:</label>
<input type="date" class="form-control" id="endDate3">
</div>
</div>
<!-- Vital Signs -->
<h3>Vital Signs</h3>
<div class="form-group">
<label for="bloodPressure">Blood Pressure:(mmHg)(Ex.120/80 mmHg)</label>
<input type="text" class="form-control" id="bloodPressure" placeholder="Enter blood pressure">
</div>
<div class="form-group">
<label for="heartRate">Heart Rate:(bpm)</label>
<input type="number" class="form-control" id="heartRate" placeholder="Enter heart rate">
</div>
<div class="form-group">
<label for="respiratoryRate">Respiratory Rate:(breaths/min)</label>
<input type="text" class="form-control" id="respiratoryRate" placeholder="Enter respiratory rate">
</div>
<div class="form-group">
<label for="temperature">Temperature:(°F)</label>
<input type="text" class="form-control" id="temperature" placeholder="Enter temperature">
</div>
<div class="form-group">
<label for="oxygenSaturation">Oxygen Saturation:(%)</label>
<input type="text" class="form-control" id="oxygenSaturation" placeholder="Enter oxygen saturation">
</div>
<!-- Laboratory Tests -->
<h3>Laboratory Tests</h3>
<div class="form-group">
<label for="tumorMarker">Tumor Marker (CA 15-3)(U/mL) (Normal range: < 30 U/mL):</label>
<input type="text" class="form-control" id="tumorMarker" placeholder="Enter tumor marker (CA 15-3)">
</div>
<div class="form-group">
<label for="estrogenReceptor">Estrogen Receptor (ER) Status:</label>
<div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="estrogenReceptor" id="epositive" value="Positive">
<label class="form-check-label" for="positive">Positive</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="estrogenReceptor" id="enegative" value="Negative">
<label class="form-check-label" for="negative">Negative</label>
</div>
</div>
</div>
<div class="form-group">
<label for="progesteroneReceptor">Progesterone Receptor (PR) Status:</label>
<div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="progesteroneReceptor" id="ppositive" value="Positive">
<label class="form-check-label" for="positive">Positive</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="progesteroneReceptor" id="pnegative" value="Negative">
<label class="form-check-label" for="negative">Negative</label>
</div>
</div>
</div>
<div class="form-group">
<label for="her2Status">HER2 Status:</label>
<div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="her2Status" id="hhpositive" value="Positive">
<label class="form-check-label" for="positive">Positive</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="her2Status" id="hnegative" value="Negative">
<label class="form-check-label" for="negative">Negative</label>
</div>
</div>
</div>
<button type="submit" class="btn btn-primary">Submit</button>
</form>
</div>
<!-- <script>
function Autofill() {
console.log("Clicked");
document.getElementById("Autofill_Button").innerHTML = "The form will be filled automatically..!!";
}
</script> -->
<!-- Bootstrap JS and Popper.js -->
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.16.0/umd/popper.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/4.5.2/js/bootstrap.min.js"></script>
</body>
</html>