192 lines
13 KiB
PHP
192 lines
13 KiB
PHP
<section class="content-header">
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<h1>
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<small></small>
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</h1>
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<ol class="breadcrumb">
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<li><a href="<?php echo base_url()?>index.php"><i class="fa fa-dashboard"></i> Dashboard</a></li>
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<li class="active"><?php echo $title;?></li>
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</ol>
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</section>
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<section class="content">
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<div class="row">
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<div class="col-xs-9">
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<div class="box box-primary">
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<div class="box-header with-border">
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<h3 class="box-title info-box-number"><?php echo $title; ?></h3>
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</div>
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<div class="box-body">
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<?php if(validation_errors()){ ?>
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<div id="mydivs" class="alert alert-danger alert-dismissable">
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<button type="button" class="close" data-dismiss="alert" aria-hidden="true">×</button>
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<h4><i class="icon fa fa-ban"></i> Alert!</h4>
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<?php echo validation_errors() ?>
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</div>
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<script>
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setTimeout(function() {
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$('#mydivs').hide('fast');
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}, 5000);
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</script>
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<?php }
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$setgambar = "pasien.jpg";
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$setidedit =$pf->row('mu_id');
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$setnama_user =$pf->row('mu_nama_user');
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$setpassword =$pf->row('mu_password');
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$setstatus =$pf->row('mu_status');
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$setnorm =$pf->row('mu_no_rekamedik');
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$setnama_lengkap =$pf->row('mu_nama_lengkap');
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$setnik =$pf->row('mu_NIK');
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$setalamatnik =$pf->row('mu_alamat_KTP');
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$setalamatdomisili =$pf->row('mu_alamat_domisili');
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$settelpon1 =$pf->row('mu_telepon_1');
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$settelpon2 =$pf->row('mu_telepon_2');
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$settgllahir =date("m-d-Y", strtotime($pf->row('mu_tanggal_lahir')));
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$setjeniskelamin =$pf->row('mu_jenis_kelamin');
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$setgd =$pf->row('mu_gol_darah');
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$setbb =$pf->row('mu_berat_badan');
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$settb =$pf->row('mu_tinggi_badan');
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$setwarnakulit =$pf->row('mu_warna_kulit');
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?>
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<form class="form-horizontal" method="post" autocomplete="off">
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<div class="box-body">
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<div class="form-group">
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<label for="namauser" class="col-sm-3 control-label">Nama User</label>
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<div class="col-sm-8">
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<input id="namauser" class="form-control" name="namauser" type="text" placeholder="Masukan Nama User" autocomplete="off" value="<?php echo $setnama_user;?>"/>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="normpasien" class="col-sm-3 control-label">No RM / Nama Pasien</label>
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<div class="col-sm-3">
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<input id="normpasien" class="form-control" name="normpasien" type="text" placeholder="Masukan No Rekamedik" autocomplete="off" value="<?php echo $setnorm;?>"/>
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</div>
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<div class="col-sm-5">
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<input type="hidden" name="id" value="<?php echo $setidedit;?>"/>
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<input id="namalengkappasien" class="form-control" name="namalengkappasien" type="text" placeholder="Masukan Nama Lengkap" autocomplete="off" value="<?php echo $setnama_lengkap;?>"/>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="nikpasien" class="col-sm-3 control-label">NIK / Alamat</label>
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<div class="col-sm-3">
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<input id="nikpasien" class="form-control" name="nikpasien" type="text" placeholder="Masukan NIK" autocomplete="off" value="<?php echo $setnik;?>" data-inputmask='"mask": "999999 999999 9999"' data-mask="" />
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</div>
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<div class="col-sm-5">
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<textarea id="alamatktp" name="alamatktp" class="form-control" placeholder="Masukan Alamat KTP" ><?php echo $setalamatnik;?></textarea>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="alamatdomisili" class="col-sm-3 control-label">Alamat Domisili</label>
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<div class="col-sm-8">
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<textarea id="alamatdomisili" name="alamatdomisili" class="form-control" placeholder="Masukan Alamat Domisili" ><?php echo $setalamatdomisili;?></textarea>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="telpon1" class="col-sm-3 control-label">Telpon</label>
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<div class="col-sm-4">
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<input id="telpon1" class="form-control" name="telpon1" type="text" placeholder="Masukan Telepon 1" autocomplete="off" value="<?php echo $settelpon1;?>"/>
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</div>
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<div class="col-sm-4">
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<input id="telpon2" class="form-control" name="telpon2" type="text" placeholder="Masukan Telepon 2" autocomplete="off" value="<?php echo $settelpon2;?>"/>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="tgllahir" class="col-sm-3 control-label">Tanggal Lahir</label>
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<div class="col-sm-5">
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<div class="input-group date" data-provide="datepicker" >
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<input class="form-control" id="tgllahir" name="tgllahir" type="text" placeholder="Masukan Tanggal Lahir" value="<?php echo $settgllahir;?>" data-inputmask="'alias': 'mm/dd/yyyy'" data-mask="" />
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<div class="input-group-addon">
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<span class="fa fa-calendar"></span>
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</div>
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</div>
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</div>
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<div class="col-sm-3">
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<select id="jkuser" name="jkuser" class="form-control select" >
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<option >Pilih Jenis Kelamin</option>
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<option <?php if($setjeniskelamin==1){echo $select="selected='selected'";}?> value="1">Laki-laki</option>
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<option <?php if($setjeniskelamin==2){echo $select="selected='selected'";}?> value="2">Perempuan</option>
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</select>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="golongandarah" class="col-sm-3 control-label">GD/ BB / TB</label>
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<div class="col-sm-2">
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<select id="golongandarah" name="golongandarah" class="form-control select" >
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<option >Pilih Gol. Darah</option>
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<option <?php if($setgd==1){echo $select="selected='selected'";}?> value="1">A</option>
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<option <?php if($setgd==2){echo $select="selected='selected'";}?> value="2">B</option>
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<option <?php if($setgd==3){echo $select="selected='selected'";}?> value="3">AB</option>
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<option <?php if($setgd==4){echo $select="selected='selected'";}?> value="4">O</option>
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</select>
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</div>
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<div class="col-sm-3">
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<div class="input-group">
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<input id="beratbadan" class="form-control" name="beratbadan" type="text" placeholder="Masukan Berat Badan" autocomplete="off" value="<?php echo $setbb;?>"/>
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<span class="input-group-addon">Kg</span>
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</div>
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</div>
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<div class="col-sm-3">
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<div class="input-group">
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<input id="tinggibadan" class="form-control" name="tinggibadan" type="text" placeholder="Masukan Tinggi Badan" autocomplete="off" value="<?php echo $settb;?>"/>
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<span class="input-group-addon">Cm</span>
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</div>
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</div>
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</div>
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</div>
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<div class="box-body">
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<div class="form-group">
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<label for="warnakulit" class="col-sm-3 control-label">Warna Kulit</label>
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<div class="col-sm-8">
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<select id="warnakulit" name="warnakulit" class="form-control select" >
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<option >Pilih Jenis Warna Kulit</option>
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<option <?php if($setwarnakulit==1){echo $select="selected='selected'";}?> value="1">Putih</option>
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<option <?php if($setwarnakulit==2){echo $select="selected='selected'";}?> value="2">Kuning Langsat</option>
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<option <?php if($setwarnakulit==3){echo $select="selected='selected'";}?> value="3">Sawo Matang</option>
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<option <?php if($setwarnakulit==4){echo $select="selected='selected'";}?> value="4">Coklat Kehitaman</option>
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<option <?php if($setwarnakulit==5){echo $select="selected='selected'";}?> value="5">Hitam Gelap</option>
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</select>
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</div>
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</div>
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</div>
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<div class="box-footer">
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<a href="<?php echo base_url();?>index.php/ps_pasien" class="btn btn-default">Cancel</a>
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</div>
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</div>
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</form>
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</div>
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</div>
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<div class="col-xs-3">
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<div class="box box-primary">
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<div class="box-header with-border">
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<h3 class="box-title info-box-number"><?php ?></h3>
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</div>
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<div class="box-body">
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<div class="col-sm-8"><img src="<?php echo base_url();?>img/pasien/<?php echo $setgambar;?>" width="200" height="200" class="user-image" alt="User Image"/></div>
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</div>
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</div>
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</div>
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</div>
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</section>
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