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Server : nginx/1.20.1 System : Linux iZ2ze9ojcl78uluczwag69Z 4.18.0-240.22.1.el8_3.x86_64 #1 SMP Thu Apr 8 19:01:30 UTC 2021 x86_64 User : www ( 1000) PHP Version : 7.3.28 Disable Function : passthru,exec,system,chroot,chgrp,chown,shell_exec,popen,proc_open,pcntl_exec,ini_alter,ini_restore,dl,openlog,syslog,readlink,symlink,popepassthru,pcntl_alarm,pcntl_fork,pcntl_waitpid,pcntl_wait,pcntl_wifexited,pcntl_wifstopped,pcntl_wifsignaled,pcntl_wifcontinued,pcntl_wexitstatus,pcntl_wtermsig,pcntl_wstopsig,pcntl_signal,pcntl_signal_dispatch,pcntl_get_last_error,pcntl_strerror,pcntl_sigprocmask,pcntl_sigwaitinfo,pcntl_sigtimedwait,pcntl_exec,pcntl_getpriority,pcntl_setpriority,imap_open,apache_setenv Directory : /www/wwwroot/0531yanglao.com/templates/wap/ |
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<title>填写老人信息</title>
<!-- <link rel="stylesheet/less" href="less.less" />
<script src="https://cdn.bootcdn.net/ajax/libs/less.js/4.1.2/less.min.js"></script> -->
<base href="{:server_url()}" />
<link rel="stylesheet" href="./css/appstyle.css" />
<link rel="stylesheet" href="./css/swiper-bundle.css">
<script src="./js/swiper-bundle.js"></script>
<!-- <link rel="stylesheet" href="./css/swiper.min.css" /> -->
</head>
<body>
<!-- 顶部 -->
<div class="dingbu">
<img src="images/fanhui.png" onclick="goBack()" />
<h4>填写老人信息</h4>
<img src="images/nav.png" class="but" />
{include file='navi'}
</div>
<header></header>
<main>
<div class="newlist">
<!-- 温馨提示 -->
<div class="wenxin">
<h4>温馨提示</h4>
<p>1.请如实填写老人信息，济南养老院养老顾问会根据老人情 况匹配合适的养老服务
</p>
<p>2.别担心，老人信息会被严格保密，仅用于养老济南网养老 顾问为老人服务前进行初步评估
</p>
</div>
<form class="form" method="">
<label> 姓名<input type="text" placeholder="请填写老人姓名" id="username" name="username" /></label>
<label> 年龄<input type="text" placeholder="请填写老人年龄" id="age" name="age" /></label>
<label> 性别 <select id="sex" name="sex">
<option value="请选择性别">请选择性别</option>
<option value="男">男</option>
<option value="女">女</option>
</select></label>
<label> 生活能力 <select id="open" name="open">
<option value="请选择老人生活能力">请选择老人生活能力</option>
<option value="完全自理">完全自理</option>
<option value="基本生活照料">基本生活照料</option>
<option value="行动不便">行动不便</option>
<option value="术后康复">术后康复</option>
<option value="长期卧床">长期卧床</option>
<option value="认知障碍">认知障碍</option>
<option value="临终关怀">临终关怀</option>
<option value="其他">其他</option>
</select></label>
<label> 预算<input type="text" id="sch" name="sch" placeholder="请填写入住预算" /></label>
<label style="height: 100px;"> 健康情况<textarea id="textarea" name="textarea" type="text"
placeholder="请填写老人身体情况，疾病史，用药历史"></textarea></label>
<label> 联系人<input type="text" id="newname" name="newname" placeholder="请填写联系人" /></label>
<label> 关系 <select id="scheel" name="scheel">
<option value="请选择性别">和老人关系</option>
<option value="配偶">朋友</option>
<option value="朋友">配偶</option>
<option value="祖孙">祖孙</option>
<option value="父母">父母</option>
<option value="其他">其他</option>
</select></label>
<label>联系人手机号<input id="phone" name="phone" type="text" placeholder="请填写联系人手机号" maxlength="11" /></label>
<label class="yanzhengma"> 验证码<input type="" name="verCode" id="verCode" placeholder="请输入验证码" maxlength="6" /><input type="button" name="" id="verCodeBtn" value="获取验证码" onclick="settime(this);" /></label>
<input type="button" id="btn7" value="确认提交">
</form>
</div>
</main>
{include file='footer'}
</body>
<script src="./js/jquery-3.6.0.js"></script>
<!-- <script src="./js/swiper.min.js"></script> -->
<script src="./js/appstyle.js"></script>
<script src="./js/page.js"></script>
<script>
box("#box5");
</script>
</html>