saisaran_task/task1.html at master · saisaran96/saisaran_task · GitHub

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<!DOCTYPE html>
<html>
<head>
	<title>Patient Form</title>
	<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.2.1/css/bootstrap.min.css" integrity="sha384-GJzZqFGwb1QTTN6wy59ffF1BuGJpLSa9DkKMp0DgiMDm4iYMj70gZWKYbI706tWS" crossorigin="anonymous">
	<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>

</head>
<body>
<div class="container">
	<h3 >Patient Form</h3>

<form id="form" >


  <div class="row">
    <div class="col">

    <label for="firstname">First Name</label>
    <input type="text" class="form-control" id="firstname" placeholder="First Name"  required></div>

    <div class="col">

    <label for="lastname">Last Name</label>
    <input type="text" class="form-control" id="lastname" placeholder="Last Name"  required>
</div>
</div>

  <div class="row">
    <div class="col">

    <label for="address">Address</label>
    <input type="text" class="form-control" id="address" placeholder="Address" required>
</div>
</div>

  <div class="row">
    <div class="col">

  	<label for="state">Select State</label>
    <select class="form-control" id="state" required>
    	<option value="">State</option>

<option value="Andhra Pradesh">Andhra Pradesh</option>
<option value="Kerala">Kerala</option>
<option value="Pondicherry">Pondicherry</option>
<option value="Tamil Nadu">Tamil Nadu</option>

    </select>
  </div>
    <div class="col">

  	<label for="City">Select City</label>
    <select class="form-control" id="City" required>
          <option value="">City</option>
      <option value="Chennai">Chennai</option>
      <option value="Madhurai">Madhuai</option>
      <option value="Bangalore">Bangalore</option>
            <option value="Hydrabad">Hydrabad</option>


    </select>
</div>

    <div class="col">

    <label for="Pin">Pin</label>
    <input type="number" min="6" class="form-control" id="Pin" placeholder="Pin" required>
</div>
</div>


 <div class="row">
    <div class="col">
    <label for="Phone">Phone</label>
    <input type="number" min="10" class="form-control"  id="Phone" placeholder="Phone" required>

</div>
<div class="col">
    <label for="email">Email</label>
    <input type="email" class="form-control" id="email" placeholder="Email" required>
   </div>
<div class="col">

    <label for="email">Emergency Contact Number</label>
    <input type="number" class="form-control" id="emergency" placeholder="Emergency Contact Number" required>

</div>

</div>

  <div class="row">
    <div class="col-md-4">

    <label for="DOB">DOB</label>
    <input type="date" class="form-control" id="dob" placeholder="dob"  required>
  </div>
<div id="parentDetail" style="display: none;">
	<div class="row">
  <div class="col">

    <label for="parentName">Parent Name</label>
    <input type="text" class="form-control" id="parentName" placeholder="Parent Name"   required>
  </div>
  <div class="col">

    <label for="parentNumber">Parent Number</label>
    <input type="number" min="10" class="form-control" id="parentNumber" placeholder="Parent Number" required>
  </div>
</div>
</div>
</div>
  <div class="row">

    <div class="col">
  <legend> Gender </legend>

  <div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="gender" id="male" value="male" required>
  <label class="form-check-label" for="male">Male</label>
</div>
<div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="gender" id="female" value="female" required>
  <label class="form-check-label" for="female">Female</label>
</div>
</div>

    <div class="col">
  <legend> Marital Status  </legend>

<div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="maritalstatus" id="married" value="married" required>
  <label class="form-check-label" for="married">married</label>
</div>
<div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="maritalstatus" id="single" value="single" required>
  <label class="form-check-label" for="single">single</label>
</div>
</div>
</div>


   <div class="row">

    <div class="col-md-4">
    	  <legend> Insurance Available </legend>

    <div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="policy" id="yes" value="yes" required>
  <label class="form-check-label" for="yes">Yes</label>
</div>
<div class="form-check form-check-inline">
  <input class="form-check-input" type="radio" name="policy" id="no" value="no" required>
  <label class="form-check-label" for="no">No</label>

</div>
</div>


<div id="policyDetail" style="display: none;">
	<div class="row">
  <div class="col">

    <label for="providerName">Provider Name</label>
    <input type="text" class="form-control" id="providerName" placeholder="Provider Name" required>
  </div>
  <div class="col">

    <label for="policyNumber">Policy Number</label>
    <input type="text" class="form-control" id="policyNumber" placeholder="policy Number" required>
  </div>
</div>
</div>

</div>
<input type="submit" id="submit" value="submit">
</form>
</div>
<script type="text/javascript">

$("#dob").change(function () {
var dob = $(this).val();
console.log(dob);
var currentDate = new Date();
console.log(currentDate);
var birthDate = new Date(dob);
    var age = currentDate.getFullYear() - birthDate.getFullYear();
    var m = currentDate.getMonth() - birthDate.getMonth();
    if (m < 0 || (m === 0 && currentDate.getDate() < birthDate.getDate())) {
        age--;
    }
    console.log(age);

    if(age < 18) {
    	$("#parentDetail").show();
    }
    else {
    	    	$("#parentDetail").hide();

    }

});

$('input[type=radio][name=policy]').change(function() {

	// alert($(this).val());

	var value = $(this).val();

	if (value == "yes") {
		$("#policyDetail").show();
	}
	else {
				$("#policyDetail").hide();

	}

});


$("#submit").click(function() {
var firstname = $('#firstname').val();
var lastname = $('#lastname').val();
var parentName= $("#parentName").val();
var phoneNumber= $("#Phone").val();
var emergency = $("#emergency").val();
var pincode = $('#pincode').val();
var name = /^[a-zA-Z]+$/;
var num = /^\d{10}$/;
var pin = /^\d{6}$/;
if (!firstname.match(name) || firstname.length == 0) {
alert("* For your first name please use alphabets only *"); // This Segment Displays The Validation Rule For Name
$("#firstname").focus();
}
 if (!lastname.match(name) || lastname.length == 0) {
alert("* For your last name please use alphabets only *"); // This Segment Displays The Validation Rule For Name
$("#lastname").focus();
}
if (!parentName.match(name) || parentName.length == 0) {
alert("* For your parent name please use alphabets only *"); // This Segment Displays The Validation Rule For Name
$("#parentName").focus();
}
if (!phoneNumber.match(num) || phoneNumber.length == 0) {
alert("* Phone no is not valid *"); // This Segment Displays The Validation Rule For Name
$("#Phone").focus();
}
if (!emergency.match(num) || emergency.length == 0) {
alert("*Emergency Phone no is not valid *"); // This Segment Displays The Validation Rule For Name
$("#emergency").focus();
}
if (!pincode.match(num) || pincode.length == 0) {
alert("*Pin Code is not valid *"); // This Segment Displays The Validation Rule For Name
$("#pincode").focus();
}
});

$(function(){
    var dtToday = new Date();

    var month = dtToday.getMonth() + 1;
    var day = dtToday.getDate();
    var year = dtToday.getFullYear();

    if(month < 10)
        month = '0' + month.toString();
    if(day < 10)
        day = '0' + day.toString();

    var maxDate = year + '-' + month + '-' + day;
    $('#dob').attr('max', maxDate);
});

</script>
	<script src="https://code.jquery.com/jquery-3.3.1.slim.min.js" integrity="sha384-q8i/X+965DzO0rT7abK41JStQIAqVgRVzpbzo5smXKp4YfRvH+8abtTE1Pi6jizo" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.14.6/umd/popper.min.js" integrity="sha384-wHAiFfRlMFy6i5SRaxvfOCifBUQy1xHdJ/yoi7FRNXMRBu5WHdZYu1hA6ZOblgut" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.2.1/js/bootstrap.min.js" integrity="sha384-B0UglyR+jN6CkvvICOB2joaf5I4l3gm9GU6Hc1og6Ls7i6U/mkkaduKaBhlAXv9k" crossorigin="anonymous"></script>
</body>
</html>