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recreate project

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2026-02-10 22:11:06 -05:00
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medical.txt
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<!-- NEW SECTION -->
<div class="row">
<!-- Medical Conditions -->
<div class="col-md-6 mb-3">
<label class="form-label">Medical Conditions (Select all that apply from the 33 items below) <span class="text-danger">*</span></label>
<div class="border rounded p-2 bg-white ps-3" style="max-height: 200px; overflow-y: auto;">
<?php
$medicalOptions = [
"None",
"ADHD (Attention-Deficit/Hyperactivity Disorder)",
"Anxiety or Emotional Disorders",
"Asthma",
"Autism Spectrum Disorder (ASD)",
"Behavioral or Conduct Disorders",
"Blindness / Vision Impairment",
"Celiac Disease (Gluten Intolerance)",
"Cerebral Palsy",
"Cystic Fibrosis",
"Depression",
"Diabetes (Type 1 or Type 2)",
"Down Syndrome",
"Dyslexia or Learning Disabilities",
"Eating Disorders",
"Eczema / Severe Skin Conditions",
"Epilepsy / Seizure Disorders",
"Hearing Impairments / Deafness",
"Heart Conditions (congenital or acquired)",
"Hemophilia / Bleeding Disorders",
"Kidney Disease",
"Migraines / Chronic Headaches",
"Obsessive-Compulsive Disorder (OCD)",
"Physical Disabilities / Mobility Impairments",
"PTSD (Post-Traumatic Stress Disorder)",
"Sickle Cell Anemia",
"Speech and Language Disorders",
"Thyroid Disorders",
"Tourette Syndrome",
"Traumatic Brain Injury (TBI)",
"Rheumatic diseases",
"Ulcerative Colitis / Crohn’s Disease",
"Other"
];
foreach ($medicalOptions as $opt): ?>
<div class="form-check">
<input class="form-check-input" type="checkbox" name="medical_conditions[][]" value="<?= esc($opt) ?>" data-base-name="medical_conditions">
<label class="form-check-label ms-1"><?= esc($opt) ?></label>
</div>
<?php endforeach; ?>
</div>
<input type="text" class="form-control mt-2 d-none medical-condition-other" name="medical_condition_other[]" placeholder="Please specify if 'Other' selected">
</div>
<!-- Allergies -->
<div class="col-md-6 mb-3">
<label class="form-label">Allergies (Select all that apply from the 24 items below) <span class="text-danger">*</span></label>
<div class="border rounded p-2 bg-white ps-3" style="max-height: 200px; overflow-y: auto; overflow-x: hidden;">
<?php
$allergyOptions = [
"None",
"Animal Dander (cats, dogs, etc.)",
"Antibiotics",
"Bee stings",
"Cockroach",
"Corn",
"Dust Mites",
"Egg",
"Fire ant stings",
"Fish",
"Fragrances / Perfumes",
"Latex",
"Milk / Dairy",
"Mold",
"Mosquito bites",
"Peanut",
"Pollen (grass, tree, weed)",
"Sesame",
"Shellfish (shrimp, crab, lobster, etc.)",
"Soy",
"Tree Nuts (almond, cashew, walnut, etc.)",
"Wasp stings",
"Wheat / Gluten",
"Other"
];
foreach ($allergyOptions as $opt): ?>
<div class="form-check">
<input class="form-check-input" type="checkbox" name="allergies[][]" value="<?= esc($opt) ?>" data-base-name="allergies">
<label class="form-check-label ms-1"><?= esc($opt) ?></label>
</div>
<?php endforeach; ?>
</div>
<input type="text" class="form-control mt-2 d-none allergy-other" name="allergy_other[]" placeholder="Please specify if 'Other' selected">
</div>
</div>