<div id="wrapper"> <div class="form-header"> <div class="header_left_img"> <img src="../images/add_requirement.png" /> </div> Patient Profile </div> <div id="navigation"> <ul> <li class="selected"> <a href="#" id="ref">Referrals</a> </li> <li><a href="#" id="ci">Flags</a> </li> <li><a href="#" id="pd">Next Of Kin</a></li> <li><a href="#" id="pi">Alerts & Directives</a> </li> <li><a href="#" id="si">Record Releases</a> </li> <li><a href="#" id="em">Employer</a> </li> <li><a href="#" id="pid">Patient ID</a> </li> </ul> </div> <asp:Label ID="AlertLbl" CssClass="AlertLabel" runat="server"></asp:Label> <asp:Label ID="Lb" runat="server" Visible="false"></asp:Label> <div id="steps"> <form id="formElem" name="formElem" action="" method="post" runat="server"> <asp:ScriptManager ID="ScriptManager1" runat="server"> </asp:ScriptManager> <fieldset class="step"> <asp:UpdatePanel ID="UpdatePanel3" runat="server"> <ContentTemplate> <legend>Referrals</legend> <p> <label>Name *</label> <asp:TextBox ID="TextBox10" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="TextBox11" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="TextBox12" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="TextBox13" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtREFmrno" runat="server"></asp:TextBox> <asp:HiddenField ID="hfREFmrno" runat="server" /> </p> <div class="line"></div> <p> <label>Refer</label> <asp:RadioButtonList ID="rdREFrefer" CssClass="radio_button form-gender" RepeatDirection="Horizontal" runat="server"> <asp:ListItem>From</asp:ListItem> <asp:ListItem>To</asp:ListItem> </asp:RadioButtonList> </p> <p> <label>Name *</label> <asp:TextBox ID="txtREFName" runat="server"></asp:TextBox> <asp:HiddenField ID="hfREFsrno" runat="server" /> </p> <p> <label>Start Date</label> <asp:TextBox ID="txtREFSDate" runat="server"></asp:TextBox> </p> <p> <label>End Date</label> <asp:TextBox ID="txtREFEDate" runat="server"></asp:TextBox> </p> <p> <label>Comments</label> <asp:TextBox ID="txtREFComents" runat="server" ></asp:TextBox> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="REFbtnAdd" runat="server" Text="Add" onclick="REFbtnAdd_Click"/> <asp:Button ID="REFbtnSave" runat="server" Text="Save" onclick="REFbtnSave_Click"/> <asp:Button ID="REFbtnUpdate" runat="server" Text="Update" onclick="REFbtnUpdate_Click"/> <asp:Button ID="REFbtnDelete" runat="server" Text="Delete" onclick="REFbtnDelete_Click"/> </p> <p class="btnmargdin" style="display:none"> <label> </label> <%--<asp:Button ID="Button13" runat="server" Text="View" /> <asp:UpdatePanel ID="UpdatePanel2" runat="server"> <ContentTemplate> <asp:Button ID="Button2" runat="server" Text="Save" /> </ContentTemplate> </asp:UpdatePanel>--%> <asp:Button ID="BtnView1" runat="server" Text="Update" /> <asp:Button ID="Button3" runat="server" CssClass="next" Text="Next" /> </p> <div class="grid"> <asp:GridView ID="GridViewREFerel" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onrowdatabound="GridViewREFerel_RowDataBound" onselectedindexchanging="GridViewREFerel_SelectedIndexChanging"> <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step"> <asp:UpdatePanel ID="UpdatePanel6" runat="server"> <ContentTemplate> <legend>Flags</legend> <p> <label>Name *</label> <asp:TextBox ID="TextBox15" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="TextBox16" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="TextBox17" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="TextBox18" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtflagmrNO" runat="server"></asp:TextBox> <asp:HiddenField ID="hfFlagmrNO" runat="server" /> </p> <div class="line"></div> <p> <label>Date</label> <asp:TextBox ID="txtFlagDate" runat="server"></asp:TextBox> </p> <p > <label> Flag Text </label> <asp:DropDownList ID="ddlFlagtext" CssClass="DropDownSlide" runat="server"> </asp:DropDownList> </p> <p> <label>Others</label> <asp:TextBox ID="txtFlagother" runat="server"></asp:TextBox> <asp:HiddenField ID="hfFlagSrno" runat="server" /> </p> <p> <label>Comments</label> <asp:TextBox ID="txtFlagComments" runat="server" ></asp:TextBox> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="flagbtnAdd" runat="server" Text="Add" onclick="flagbtnAdd_Click"/> <asp:Button ID="flagbtnSave" runat="server" Text="Save" onclick="flagbtnSave_Click" /> <asp:Button ID="flagbtnUpdate" runat="server" Text="Update" onclick="flagbtnUpdate_Click" /> <asp:Button ID="flagbtnDelete" runat="server" Text="Delete" onclick="flagbtnDelete_Click" /> </p> <div class="grid"> <asp:GridView ID="GridViewFlag" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onrowdatabound="GridViewFlag_RowDataBound" onselectedindexchanging="GridViewFlag_SelectedIndexChanging"> <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step"> <asp:UpdatePanel ID="UpdatePanel7" runat="server"> <ContentTemplate> <legend>Next Of Kin</legend> <p> <label>Name *</label> <asp:TextBox ID="TextBox20" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="TextBox21" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="TextBox22" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="TextBox23" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtNOKmrno" runat="server"></asp:TextBox> <asp:HiddenField ID="hfNOKmrno" runat="server" /> </p> <div class="line"></div> <p> <label>Name</label> <asp:TextBox ID="txtNOKname" runat="server"></asp:TextBox> </p> <p> <label>Phone</label> <asp:TextBox ID="txtNOKphone" runat="server"></asp:TextBox> </p> <p> <label>Cell Phone</label> <asp:TextBox ID="txtNOKCellphone" runat="server"></asp:TextBox> <asp:HiddenField ID="hfNOKsrNo" runat="server" /> </p> <p> <label>Relationship To Patient</label> <asp:TextBox ID="txtNOKrelationToPatient" runat="server"></asp:TextBox> </p> <p> <label>Type</label> <asp:RadioButtonList ID="rdNOKType" CssClass="radio_button form-gender" RepeatDirection="Horizontal" runat="server"> <asp:ListItem>Primary</asp:ListItem> <asp:ListItem>Secondary</asp:ListItem> </asp:RadioButtonList> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="NOKbtnAdd" runat="server" Text="Add" onclick="NOKbtnAdd_Click" /> <asp:Button ID="NOKbtnSave" runat="server" Text="Save" onclick="NOKbtnSave_Click"/> <asp:Button ID="NOKbtnUpdate" runat="server" Text="Update" onclick="NOKbtnUpdate_Click" /> <asp:Button ID="NOKbtnDelete" runat="server" Text="Delete" onclick="NOKbtnDelete_Click" /> </p> <div class="grid"> <asp:GridView ID="GridViewNOK" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onrowdatabound="GridViewNOK_RowDataBound" onselectedindexchanging="GridViewNOK_SelectedIndexChanging"> <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step" id="abc"> <legend>Alerts & Directives</legend> <asp:UpdatePanel ID="UpdatePanel2" runat="server"> <ContentTemplate> <p> <label>Name *</label> <asp:TextBox ID="txtADFname" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="txtADLname" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="txtADdob" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="txtADssn" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtADMrno" runat="server"></asp:TextBox> <asp:HiddenField ID="hfmrNo" runat="server" /> </p> <div class="line"></div> <p> <label> Date </label> <asp:TextBox ID="txtADDAte" CssClass="datepicker" runat="server" ></asp:TextBox> <asp:HiddenField ID="HFAdSrno" runat="server" /> </p> <p> <label> Type</label> <asp:DropDownList ID="DDLAdtype" CssClass="DropDownSlide" runat="server"> <asp:ListItem>Choose one</asp:ListItem> <asp:ListItem>Alerts</asp:ListItem> <asp:ListItem>Advance Directives</asp:ListItem> <asp:ListItem>Other</asp:ListItem> </asp:DropDownList> </p> <p> <label> Name</label> <asp:DropDownList ID="DDLAdName" CssClass="DropDownSlide" runat="server"> <asp:ListItem>Choose one</asp:ListItem> <asp:ListItem>Allergy</asp:ListItem> <asp:ListItem>Adverse Reaction</asp:ListItem> <asp:ListItem>Med Reaction</asp:ListItem> <asp:ListItem>Other</asp:ListItem> <asp:ListItem>Privacy</asp:ListItem> <asp:ListItem>Alert</asp:ListItem> </asp:DropDownList> </p> <p> <label> Details</label> <asp:TextBox TextMode="MultiLine" ID="txtADdetails" runat="server" Columns="1" Rows="3"></asp:TextBox> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="ADbtnAdd" runat="server" Text="Add" onclick="ADbtnAdd_Click" /> <asp:Button ID="ADbtnSave" runat="server" Text="Save" onclick="ADbtnSave_Click"/> <asp:Button ID="ADbtnUpdate" runat="server" Text="Update" onclick="ADbtnUpdate_Click"/> <asp:Button ID="ADbtnDelete" runat="server" Text="Delete" onclick="ADbtnDelete_Click"/> </p> <div class="grid"> <asp:GridView ID="GridViewAD" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onrowdatabound="GridViewAD_RowDataBound" onselectedindexchanging="GridViewAD_SelectedIndexChanging"> <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step"> <legend>Record Releases</legend> <asp:UpdatePanel ID="UpdatePanel4" runat="server"> <ContentTemplate> <p> <label>Name *</label> <asp:TextBox ID="txtRRFname" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="txtRRLname" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="txtRRdob" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="txtRRssn" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtRRMrno" runat="server"></asp:TextBox> </p> <div class="line"></div> <p > <label> </label> </p> <p> <label> Release To </label> <asp:TextBox ID="txtRRreleaseTo" runat="server" ></asp:TextBox> <asp:HiddenField ID="hfRRmrNO" runat="server" /> </p> <p> <label>Release Date</label> <asp:TextBox ID="txtRRrelaseDate" CssClass="datepicker" runat="server" ></asp:TextBox> </p> <p> <label>Released By</label> <asp:TextBox ID="txtRRreleaseby" runat="server" ></asp:TextBox> <asp:HiddenField ID="hfRRsrno" runat="server" /> </p> <p> <label> Comments</label> <asp:TextBox ID="txtRRcoments" runat="server" ></asp:TextBox> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="RRbtnAdd" runat="server" Text="Add" onclick="RRbtnAdd_Click"/> <asp:Button ID="RRbtnSave" runat="server" Text="Save" onclick="RRbtnSave_Click"/> <asp:Button ID="RRbtnUpdate" runat="server" Text="Update" onclick="RRbtnUpdate_Click"/> <asp:Button ID="RRbtnDelete" runat="server" Text="Delete" onclick="RRbtnDelete_Click"/> </p> <div class="grid"> <asp:GridView ID="GridViewRR" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onrowdatabound="GridViewRR_RowDataBound" onselectedindexchanging="GridViewRR_SelectedIndexChanging"> <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step"> <asp:UpdatePanel ID="UpdatePanel5" runat="server"> <ContentTemplate> <legend>Employer / School</legend> <p> <label>Name *</label> <asp:TextBox ID="txtFname" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="txtLname" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="txtDOB" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="txtSSN" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtMRno" runat="server"></asp:TextBox> </p> <div class="line"></div> <p > <label> Work Status </label> <asp:DropDownList ID="ddlWorkStatus" CssClass="DropDownSlide" runat="server"> <asp:ListItem>Choose one</asp:ListItem> <asp:ListItem>Part Time</asp:ListItem> <asp:ListItem>Retired</asp:ListItem> <asp:ListItem>Student</asp:ListItem> <asp:ListItem>On Job</asp:ListItem> <asp:ListItem>Business</asp:ListItem> </asp:DropDownList> </p> <p> <label> Phone No </label> <asp:TextBox ID="txtPhoneNo" runat="server" ></asp:TextBox> </p> <p> <label> Name Of School</label> <asp:TextBox ID="txtNameOfEmp" runat="server" Width="410px"></asp:TextBox> </p> <p> <label> Details</label> <asp:TextBox TextMode="MultiLine" ID="txtDetails" runat="server" Columns="1" Rows="3"></asp:TextBox> </p> <p class="btnmargin"> <label> </label> <asp:Button ID="buttonSave" runat="server" Text="Save" onclick="buttonSave_Click1" /> <asp:Button ID="buttonUpdate" runat="server" Text="Update" onclick="buttonUpdate_Click1" /> </p> </ContentTemplate> </asp:UpdatePanel> </fieldset> <fieldset class="step"> <legend>Patient ID</legend> <asp:UpdatePanel ID="UpdatePanel1" runat="server"> <ContentTemplate> <p> <label>Name *</label> <asp:TextBox ID="txtPfirstName" CssClass="number" runat="server"></asp:TextBox> <asp:TextBox ID="txtPLname" CssClass="number" runat="server"></asp:TextBox> </p> <p> <label> DOB</label> <asp:TextBox ID="txtPDob" runat="server"></asp:TextBox> </p> <p> <label> SSN</label> <asp:TextBox ID="txtPssn" onkeypress="CheckNumeric(event);" runat="server"></asp:TextBox></p> <p > <label> MR No </label> <asp:TextBox onkeypress="CheckNumeric(event);" ID="txtPmrno" runat="server"></asp:TextBox> </p> <div class="line"></div> <p > <label> </label> </p> <p> <label> ID Type </label> <asp:TextBox ID="txtPidtype" runat="server" ></asp:TextBox> <asp:HiddenField ID="PIDHFSrno" runat="server" /> </p> <p> <label> Name</label> <asp:TextBox ID="TxtPname" runat="server" ></asp:TextBox> </p> <p> <label> ID Value</label> <asp:TextBox ID="txtPidValue" runat="server" ></asp:TextBox> <asp:HiddenField ID="HfPIDMrNo" runat="server" /> </p> <p> <label> Expiry Date</label> <asp:TextBox ID="txtExpiryDate" CssClass="datepicker" runat="server" ></asp:TextBox> </p> <p style="display:none"> <label> Attached Files</label> <asp:Image ID="Pimgul" runat="server"/> <asp:FileUpload ID="FUl" runat="server" /> <br /> <asp:Button ID="btnPupload" runat="server" Text="Upload" /> </p> <p class="btnmargin" style="padding-bottom:50px"> <label> </label> <asp:Button ID="PbtnAdd" runat="server" Text="Add" onclick="PbtnAdd_Click"/> <asp:Button ID="PbtnSave" runat="server" Text="Save" onclick="PbtnSave_Click"/> <asp:Button ID="PbtnUpdate" runat="server" Text="Update" onclick="PbtnUpdate_Click"/> <asp:Button ID="PbtnDelete" runat="server" Text="Delete" onclick="PbtnDelete_Click"/> </p> <div class="grid"> <asp:GridView ID="GridViewPatientID" runat="server" GridLines="None" CssClass="mgrid" AutoGenerateSelectButton="true" EmptyDataText=" table is empty." onselectedindexchanged="GridViewPatientID_SelectedIndexChanged" onrowdatabound="GridViewPatientID_RowDataBound1" onselectedindexchanging="GridViewPatientID_SelectedIndexChanging" > <AlternatingRowStyle CssClass="AlternatingRowStyle" /> <SelectedRowStyle CssClass="rowslect" /> <HeaderStyle CssClass="GridViewHeaderStyle" /> <RowStyle CssClass="row" /> <FooterStyle CssClass="foter" /> </asp:GridView> </div> </ContentTemplate> </asp:UpdatePanel> </fieldset> </form> </div> </div>
<fieldset class="step">
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