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