143 lines
8.2 KiB
PHP
143 lines
8.2 KiB
PHP
<SCRIPT LANGUAGE="JavaScript">
|
|
function stopjam(){
|
|
var d = new Date();
|
|
var curr_hour = d.getHours();
|
|
var curr_min = d.getMinutes();
|
|
var curr_sec = d.getSeconds();
|
|
document.getElementById('stop_daftar').value=(curr_hour + ":" + curr_min+ ":" + curr_sec);
|
|
}
|
|
</SCRIPT>
|
|
|
|
|
|
<?php /*
|
|
function datediff($d1, $d2){
|
|
$d1 = (is_string($d1) ? strtotime($d1) : $d1);
|
|
$d2 = (is_string($d2) ? strtotime($d2) : $d2);
|
|
$diff_secs = abs($d1 - $d2);
|
|
$base_year = min(date("Y", $d1), date("Y", $d2));
|
|
$diff = mktime(0, 0, $diff_secs, 1, 1, $base_year);
|
|
return array( "years" => date("Y", $diff) - $base_year, "months_total" => (date("Y", $diff) - $base_year) * 12 + date("n", $diff) - 1, "months" => date("n", $diff) - 1, "days_total" => floor($diff_secs / (3600 * 24)), "days" => date("j", $diff) - 1, "hours_total" => floor($diff_secs / 3600), "hours" => date("G", $diff), "minutes_total" => floor($diff_secs / 60), "minutes" => (int) date("i", $diff), "seconds_total" => $diff_secs, "seconds" => (int) date("s", $diff) );
|
|
} //$a = datediff("1979-02-07", "2009-08-24");
|
|
//echo 'umur '.$a['years'].' tahun '.$a['months'].' bulan'; */
|
|
?>
|
|
|
|
|
|
|
|
|
|
<div id='msg'></div>
|
|
<div id="list_data"></div>
|
|
<fieldset class="fieldset"><legend>Identitas Pasien</legend>
|
|
<table width="100%" border="0" cellpadding="0" cellspacing="0" title=" From Ini Berfungsi Sebagai Form Entry Data Pasien Baru.">
|
|
<tr>
|
|
<td width="20%">Nama Lengkap Pasien</td>
|
|
<td width="56%"><input title="NAMA" class="text" type="text" <?php if($_POST['nama_lgkp']){ echo"value='".$_POST['nama_lgkp']."'";} ?> name="NAMA" size="30" value="<?=$m_pasien->NAMA?>" id="AWAL" /></td>
|
|
<td width="24%" rowspan="11" valign="top"> Jenis Kelamin :<br />
|
|
<input type="radio" name="JENISKELAMIN" value="L" <?php if($m_pasien->JENISKELAMIN=="L" || $m_pasien->JENISKELAMIN=="l" || $_POST['JENISKELAMIN'] =="1")echo "Checked";?>/>
|
|
Laki-laki<br />
|
|
<input type="radio" name="JENISKELAMIN" value="P" <?php if($m_pasien->JENISKELAMIN=="P" || $_POST['JENISKELAMIN'] =="2")echo "Checked";?>/>
|
|
Perempuan<br />
|
|
<br />
|
|
Status Perkawinan :<br />
|
|
|
|
<input type="radio" name="STATUS" value="1" <?php if($m_pasien->STATUS=="1" || $_POST['KAWIN']=="1")echo "Checked";?>/>
|
|
Belum Kawin<br />
|
|
<input type="radio" name="STATUS" value="2" <?php if($m_pasien->STATUS=="2" || $_POST['KAWIN']=="2")echo "Checked";?> />
|
|
Kawin<br />
|
|
<input type="radio" name="STATUS" value="3" <?php if($m_pasien->STATUS=="3" || $_POST['KAWIN']=="3")echo "Checked";?>/>
|
|
Janda / Duda<br /><br />
|
|
|
|
Pendidikan Terakhir :<br />
|
|
<input type="radio" name="PENDIDIKAN" value="1" <?php if($m_pasien->PENDIDIKAN=="1" || $_POST['PENDIDIKAN']=="1" )echo "Checked";?> />
|
|
SD<br />
|
|
<input type="radio" name="PENDIDIKAN" value="2" <?php if($m_pasien->PENDIDIKAN=="2" || $_POST['PENDIDIKAN']=="2" )echo "Checked";?> />
|
|
SLTP<br />
|
|
<input type="radio" name="PENDIDIKAN" value="3" <?php if($m_pasien->PENDIDIKAN=="3" || $_POST['PENDIDIKAN']=="3" )echo "Checked";?> />
|
|
SMU<br />
|
|
<input type="radio" name="PENDIDIKAN" value="4" <?php if($m_pasien->PENDIDIKAN=="4" || $_POST['PENDIDIKAN']=="4" )echo "Checked";?> />
|
|
D3/Akademik<br />
|
|
<input type="radio" name="PENDIDIKAN" value="5" <?php if($m_pasien->PENDIDIKAN=="5" || $_POST['PENDIDIKAN']=="5" )echo "Checked";?> />
|
|
Universitas<br /><br />
|
|
|
|
Agama :<br />
|
|
<input type="radio" name="AGAMA" value="1" <?php if($m_pasien->AGAMA=="1" || $_POST['AGAMA']=="1" )echo "Checked";?> />
|
|
Islam<br />
|
|
|
|
<input type="radio" name="AGAMA" value="2" <?php if($m_pasien->AGAMA=="2" || $_POST['AGAMA']=="2" )echo "Checked";?>/>
|
|
Kristen Protestan<br />
|
|
|
|
<input type="radio" name="AGAMA" value="3" <?php if($m_pasien->AGAMA=="3" || $_POST['AGAMA']=="3" )echo "Checked";?>/>
|
|
Katholik<br />
|
|
|
|
<input type="radio" name="AGAMA" value="4" <?php if($m_pasien->AGAMA=="4" || $_POST['AGAMA']=="4" )echo "Checked";?>/>
|
|
Hindu<br />
|
|
|
|
<input type="radio" name="AGAMA" value="5" <?php if($m_pasien->AGAMA=="5" || $_POST['AGAMA']=="5" )echo "Checked";?>/>
|
|
Budha<br />
|
|
|
|
<input type="radio" name="AGAMA" value="6" <?php if($m_pasien->AGAMA=="6" || $_POST['AGAMA']=="6" || $_POST['AGAMA']=="7" )echo "Checked";?>/>
|
|
Lain - lain </td>
|
|
</tr>
|
|
<tr>
|
|
<td>Tempat Tanggal Lahir</td>
|
|
<td>Tempat
|
|
<input type="text" value="<?php if($m_pasien->TEMPAT || $_POST['tmpt_lhr']){ echo $_POST['tmpt_lhr'].$m_pasien->TEMPAT; }?>" class="text" name="TEMPAT" size="15" />
|
|
<input onblur="calage(this.value,'umur');" type="text" class="text" value="<?php if($m_pasien->TGLLAHIR || $_POST['tgl_lhr']){ echo $_POST['tgl_lhr'].$m_pasien->TGLLAHIR; }?>" name="TGLLAHIR" id="TGLLAHIR" size="20" /> ex : 1999/09/29</td>
|
|
</tr>
|
|
<tr>
|
|
<td>Umur Pasien</td>
|
|
<td>
|
|
<?php
|
|
$a = datediff($_POST['tgl_lhr'], date("Y/m/d"));
|
|
?><span id="umurc">
|
|
<input class="text" type="text" value="<?php echo $a['years'].' tahun '.$a['months'].' bulan '.$a['days'].' hari'; ?>" name="umur" id="umur" size="45" />
|
|
</span></td>
|
|
</tr>
|
|
<tr>
|
|
<td valign="top">Alamat Pasien</td>
|
|
<td colspan="1"><input name="ALAMAT" class="text" type="text" value="<?php if($m_pasien->ALAMAT || $_POST['ALAMAT']){echo $_POST['ALAMAT'].$m_pasien->ALAMAT;} ?>" size="45" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>Kelurahan</td>
|
|
<td><input class="text" type="text" value="<?php if($m_pasien->KELURAHAN || $_POST['KELURAHAN']){ echo $_POST['KELURAHAN'].$m_pasien->KELURAHAN;}?>" name="KELURAHAN" size="25" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>Kecamatan</td>
|
|
<td><input class="text" type="text" value="<?php if($m_pasien->KECAMATAN || $_POST['KECAMATAN']){ echo $_POST['KECAMATAN'].$m_pasien->KECAMATAN;}?>" name="KECAMATAN" size="25" /><input type="hidden" value="<?=$_POST['KDKECAMATAN']?>" name="KDKECAMATAN" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>Kota</td>
|
|
<td><input class="text" value="<?php if($m_pasien->KOTA || $_POST['KOTA']){echo $_POST['KOTA'].$m_pasien->KOTA;}?>" type="text" name="KOTA" size="25" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>No Telepon / HP Pasien</td>
|
|
<td><input class="text" value="<?php if($m_pasien->NOTELP || $_POST['NOTELP']){echo $_POST['NOTELP'].$m_pasien->NOTELP;}?>" type="text" name="NOTELP" size="25" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>No KTP </td>
|
|
<td><input class="text" value="<?php if($m_pasien->NOKTP || $_POST['nik']){echo $_POST['nik'].$m_pasien->NOKTP;}?>" type="text" name="NOKTP" size="25" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>Nama Suami / Orang Tua Pasien</td>
|
|
<td><input class="text" type="text" value="<?php if($m_pasien->SUAMI_ORTU || $_POST['SUAMI_ORTU']){echo $_POST['SUAMI_ORTU'].$m_pasien->SUAMI_ORTU;}?>" name="SUAMI_ORTU" id="SUAMI_ORTU" size="25" /></td>
|
|
</tr>
|
|
<tr valign="top">
|
|
<td valign="top">Pekerjaan Pasien / Orang Tua</td>
|
|
<td><input class="text" type="text" value="<?php if($m_pasien->PEKERJAAN || $_POST['pkrjn']){echo $_POST['pkrjn'].$m_pasien->SUAMI_ORTU;}?>" name="PEKERJAAN" size="25" /></td>
|
|
</tr>
|
|
<tr>
|
|
<td valign="top"> </td>
|
|
<td colspan="2"><input type='hidden' name='stop_daftar' id='stop_daftar' /></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="3" align="right"><input type="submit" name="daftar" class="text" value=" S a v e "
|
|
onclick="stopjam();submitformpendaftaran(document.getElementById('myform'),'models/pendaftaran.php','msg',validatetask);
|
|
document.getElementById('msgid').value=document.getElementById('msg').innerHTML;
|
|
if (document.getElementById('msgid').value=='.'){alert('Simpan Data Sukses');window.location='<?php echo _BASE_;?>index.php?link=2';return false;} else {return false;}"/></td>
|
|
</tr>
|
|
</table>
|
|
<input type="text" id="msgid" name="msgid" style="border:1px #FFF solid; width:0px; height:0px;">
|
|
<br>
|
|
</fieldset>
|
|
|
|
|
|
|