|
Server IP : 172.16.15.8 / Your IP : 3.14.132.178 Web Server : Apache System : Linux zeus.vwu.edu 4.18.0-553.27.1.el8_10.x86_64 #1 SMP Wed Nov 6 14:29:02 UTC 2024 x86_64 User : apache ( 48) PHP Version : 7.2.24 Disable Function : NONE MySQL : OFF | cURL : ON | WGET : ON | Perl : ON | Python : ON Directory (0755) : /home/inieves/www/ |
| [ Home ] | [ C0mmand ] | [ Upload File ] |
|---|
<!--
File: patientForm.html
Assignment: Hone Project 10
Due: Apr. 10, 2017
Author: Ismael Nieves
Goal: (a) Create a login and password page, leading to the patient info page.
(b) Create a 2nd page that asks for name, phone and gender. (c) Create a following page that
has 5 checkboxes for symptoms and use an array for the name of the check boxes. (d) The
final page should display all the previous information entered.
-->
<HTML>
<BODY background = "https://orig00.deviantart.net/1be0/f/2007/163/b/e/umbrella_corp_wallpaper_01_by_disease_of_machinery.png">
<BODY STYLE = "background-color:black; color:white; font-family:algerian;">
<CENTER>
<H2 STYLE = "color:white; font-size:200% border:2px; border-style:solid; border-color:white;">
Patient Database log-in page
</H2>
<FORM action=PatientInfoForm.php method=post>
Enter your log-in:
<INPUT type=textbox name=name>
<P>
Enter your password:
<INPUT type=password name=pass>
<P>
<INPUT type=submit value=Submit>
<INPUT type=reset value=Reset>
</FORM>
<P>
<A HREF=index.html> Homepage </A>
</CENTER>
</BODY>
</HTML>