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57 lines (50 loc) · 3.01 KB
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q3_name[first] firstname
q3_name[last] lastname
dob date of Birth
q231_sex sex
q250_age Age
q247_contactNumber contactNumber
q225_email Email
q4_address4[addr_line1] street add 1
q4_address4[addr_line2] street add 2
q4_address4[city] City
q4_address4[state] State
q4_address4[postal] zipcode
q232_maritalStatus232 maritialstatus
q243_fullName emername
q73_relationship emerRelation
q248_contactNumber248 emercontact
q246_aadharNumber aadharNumber
q237_panNumber panNumber
q43_healthInsurance Insurance
q244_previousIllness previousIllness
q245_travelHistory History
q249_severity Severity
q240_symptoms Symptoms
myfile1 attach 1
myfile2 attach 2
addpat submit
<label class="form-sub-label" for="month_242" id="sublabel_242_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[required, limitDate]" id="day_242" name="q242_dateOf[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" required="" autoComplete="off" aria-labelledby="label_242 sublabel_242_day" />
<span class="date-separate" aria-hidden="true">
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</span>
<label class="form-sub-label" for="day_242" id="sublabel_242_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[required, limitDate]" id="year_242" name="q242_dateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" required="" autoComplete="off" aria-labelledby="label_242 sublabel_242_year" />
<label class="form-sub-label" for="year_242" id="sublabel_242_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]" name="dob" id="lite_mode_242" size="12" data-maxlength="12" maxLength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_242 sublabel_242_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_242_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_242" id="sublabel_242_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[required, limitDate]" id="month_242" name="q242_dateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" required="" autoComplete="off" aria-labelledby="label_242 sublabel_242_month" />
<span class="date-separate" aria-hidden="true">
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</span>