duva/index.html at main · arthmohan/duva · GitHub

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<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <meta name="viewport" content="width=device-width, initial-scale=1.0">
    <title>Medical Information Form - Duva</title>
    <link rel="stylesheet" href="styles.css">
</head>
<body>
    <header>
        <img src="Duva Logo.svg" height="100em">
    </header>
    <div class="container">
        <div class="heading"><h2>Medical Information Form</h2></div>
        <br>
        <form id="medicalForm">
            <label for="name">Name:</label>
            <input type="text" id="name" name="name">

            <label for="age">Age:</label>
            <input type="number" id="age" name="age">

            <label for="sex">Sex:</label>
            <select id="sex" name="sex">
                <option value="male">Male</option>
                <option value="female">Female</option>
                <option value="transgender">Transgender</option>
                <option value="other">Other</option>
            </select>

            <label for="bloodGroup">Blood Group:</label>
            <input type="text" id="bloodGroup" name="bloodGroup">

            <label for="medications">Medications currently using:</label>
            <textarea id="medications" name="medications" rows="3"></textarea>

            <label for="chronicConditions">Chronic medical conditions (if any):</label>
            <textarea id="chronicConditions" name="chronicConditions" rows="3"></textarea>

            <label for="emergencyContactName">Emergency Contact Name:</label>
            <input type="text" id="emergencyContactName" name="emergencyContactName">

            <label for="emergencyContactPhone">Emergency Contact Phone:</label>
            <input type="tel" id="emergencyContactPhone" name="emergencyContactPhone">

            <label for="allergies">Any known allergies:</label>
            <textarea id="allergies" name="allergies" rows="3"></textarea>

            <button type="submit">Submit</button>
        </form>
    </div>
    <script src="formScript.js"></script>
</body>
</html>