<?php 
ob_start();   
session_start();
$conn=mysqli_connect("localhost","crmsahavasco","sa123AWEsadfa");
if(!$conn)
{
die("could not connect to".mysqli_error());
}
else
{
mysqli_select_db($conn,"crmsahavasco_kanakveda");
}
 $result = mysqli_query($conn,"SELECT * FROM appointment_details WHERE username='".$_REQUEST['username']."' AND password='".$_REQUEST['password']."'");
	
    if(mysqli_num_rows($result) > 0) {
      $_SESSION['is_logged_in'] = 1;
	  }
	if(isset($_SESSION['is_logged_in'])) {  
?>

<!doctype html>
<html lang="en">
  <head>
  	<title>Contact Form 10</title>
    <meta charset="utf-8">
    <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">

	<link href='https://fonts.googleapis.com/css?family=Roboto:400,100,300,700' rel='stylesheet' type='text/css'>

	<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/font-awesome/4.7.0/css/font-awesome.min.css">
	<link href='https://fonts.googleapis.com/css?family=Roboto' rel='stylesheet'>
	 <link rel="stylesheet" href="./style_signature.css">


	<link rel="stylesheet" href="style_new.css">

	</head>
	
<script>
function validateForm() {
    
    var checkboxChecked = false;
    var checkboxes = document.getElementsByName("past_history[]");
    for (var i = 0; i < checkboxes.length; i++) {
        if (checkboxes[i].checked) {
            checkboxChecked = true;
            break;
        }
    }
	
	 if (!checkboxChecked) {
        alert("Please select at least one checkbox option. Past History");
        return false;
    }
	
	 var checkboxChecked1 = false;
	 var checkboxes1 = document.getElementsByName("father_past_history[]");
    for (var i = 0; i < checkboxes1.length; i++) {
        if (checkboxes1[i].checked) {
            checkboxChecked1 = true;
            break;
        }
    }
	 if (!checkboxChecked1) {
        alert("Please select at least one checkbox option. Father Past History");
        return false;
    }
	
	
	 var checkboxChecked2 = false;
	 var checkboxes2 = document.getElementsByName("Gfather_past_history[]");
    for (var i = 0; i < checkboxes2.length; i++) {
        if (checkboxes2[i].checked) {
            checkboxChecked2 = true;
            break;
        }
    }
	 if (!checkboxChecked2) {
        alert("Please select at least one checkbox option. Paternal Grand Father");
        return false;
    }


 var checkboxChecked3 = false;
	 var checkboxes3 = document.getElementsByName("GMfather_past_history[]");
    for (var i = 0; i < checkboxes3.length; i++) {
        if (checkboxes3[i].checked) {
            checkboxChecked3 = true;
            break;
        }
    }
	 if (!checkboxChecked3) {
        alert("Please select at least one checkbox option. Paternal Grand Mother");
        return false;
    }
	
	
	var checkboxChecked4 = false;
	 var checkboxes4 = document.getElementsByName("mother_past_history[]");
    for (var i = 0; i < checkboxes4.length; i++) {
        if (checkboxes4[i].checked) {
            checkboxChecked4 = true;
            break;
        }
    }
	 if (!checkboxChecked4) {
        alert("Please select at least one checkbox option. Mother");
        return false;
    }
	
	// Maternal Grandmother Past History
var checkboxCheckedGM = false;
var checkboxesGM = document.getElementsByName("GMmother_past_history[]");
for (var i = 0; i < checkboxesGM.length; i++) {
    if (checkboxesGM[i].checked) {
        checkboxCheckedGM = true;
        break;
    }
}
if (!checkboxCheckedGM) {
    alert("Please select at least one checkbox option for Maternal Grandmother Past History.");
    return false;
}

// Maternal Grandfather Past History
var checkboxCheckedGMP = false;
var checkboxesGMP = document.getElementsByName("Gmother_past_history[]");
for (var i = 0; i < checkboxesGMP.length; i++) {
    if (checkboxesGMP[i].checked) {
        checkboxCheckedGMP = true;
        break;
    }
}
if (!checkboxCheckedGMP) {
    alert("Please select at least one checkbox option for Maternal Grandfather Past History.");
    return false;
}

// Developmental History
var checkboxCheckedDev = false;
var checkboxesDev = document.getElementsByName("developmental_history[]");
for (var i = 0; i < checkboxesDev.length; i++) {
    if (checkboxesDev[i].checked) {
        checkboxCheckedDev = true;
        break;
    }
}
if (!checkboxCheckedDev) {
    alert("Please select at least one checkbox option for Developmental History.");
    return false;
}

// Menses
var checkboxCheckedMenses = false;
var checkboxesMenses = document.getElementsByName("menses[]");
for (var i = 0; i < checkboxesMenses.length; i++) {
    if (checkboxesMenses[i].checked) {
        checkboxCheckedMenses = true;
        break;
    }
}
if (!checkboxCheckedMenses) {
    alert("Please select at least one checkbox option for Menses.");
    return false;
}

// Leucorrhoea
var checkboxCheckedLeucorrhoea = false;
var checkboxesLeucorrhoea = document.getElementsByName("leucorrhoea[]");
for (var i = 0; i < checkboxesLeucorrhoea.length; i++) {
    if (checkboxesLeucorrhoea[i].checked) {
        checkboxCheckedLeucorrhoea = true;
        break;
    }
}
if (!checkboxCheckedLeucorrhoea) {
    alert("Please select at least one checkbox option for Leucorrhoea.");
    return false;
}

// Addiction
var checkboxCheckedAddiction = false;
var checkboxesAddiction = document.getElementsByName("addiction[]");
for (var i = 0; i < checkboxesAddiction.length; i++) {
    if (checkboxesAddiction[i].checked) {
        checkboxCheckedAddiction = true;
        break;
    }
}
if (!checkboxCheckedAddiction) {
    alert("Please select at least one checkbox option for Addiction.");
    return false;
}

// Water Thirst
var checkboxCheckedWaterThirst = false;
var checkboxesWaterThirst = document.getElementsByName("water_thirst[]");
for (var i = 0; i < checkboxesWaterThirst.length; i++) {
    if (checkboxesWaterThirst[i].checked) {
        checkboxCheckedWaterThirst = true;
        break;
    }
}
if (!checkboxCheckedWaterThirst) {
    alert("Please select at least one checkbox option for Water Thirst.");
    return false;
}

// Desire
var checkboxCheckedDesire = false;
var checkboxesDesire = document.getElementsByName("desire[]");
for (var i = 0; i < checkboxesDesire.length; i++) {
    if (checkboxesDesire[i].checked) {
        checkboxCheckedDesire = true;
        break;
    }
}
if (!checkboxCheckedDesire) {
    alert("Please select at least one checkbox option for Desire.");
    return false;
}

// Aversion
var checkboxCheckedAversion = false;
var checkboxesAversion = document.getElementsByName("aversion[]");
for (var i = 0; i < checkboxesAversion.length; i++) {
    if (checkboxesAversion[i].checked) {
        checkboxCheckedAversion = true;
        break;
    }
}
if (!checkboxCheckedAversion) {
    alert("Please select at least one checkbox option for Aversion.");
    return false;
}

// Appetite
var checkboxCheckedAppetite = false;
var checkboxesAppetite = document.getElementsByName("appetite[]");
for (var i = 0; i < checkboxesAppetite.length; i++) {
    if (checkboxesAppetite[i].checked) {
        checkboxCheckedAppetite = true;
        break;
    }
}
if (!checkboxCheckedAppetite) {
    alert("Please select at least one checkbox option for Appetite.");
    return false;
}

// Stool
var checkboxCheckedStool = false;
var checkboxesStool = document.getElementsByName("stool[]");
for (var i = 0; i < checkboxesStool.length; i++) {
    if (checkboxesStool[i].checked) {
        checkboxCheckedStool = true;
        break;
    }
}
if (!checkboxCheckedStool) {
    alert("Please select at least one checkbox option for Stool.");
    return false;
}

// Urine
var checkboxCheckedUrine = false;
var checkboxesUrine = document.getElementsByName("urine[]");
for (var i = 0; i < checkboxesUrine.length; i++) {
    if (checkboxesUrine[i].checked) {
        checkboxCheckedUrine = true;
        break;
    }
}
if (!checkboxCheckedUrine) {
    alert("Please select at least one checkbox option for Urine.");
    return false;
}

// Sleep
var checkboxCheckedSleep = false;
var checkboxesSleep = document.getElementsByName("sleep[]");
for (var i = 0; i < checkboxesSleep.length; i++) {
    if (checkboxesSleep[i].checked) {
        checkboxCheckedSleep = true;
        break;
    }
}
if (!checkboxCheckedSleep) {
    alert("Please select at least one checkbox option for Sleep.");
    return false;
}

// Perspiration
var checkboxCheckedPerspiration = false;
var checkboxesPerspiration = document.getElementsByName("perspiration[]");
for (var i = 0; i < checkboxesPerspiration.length; i++) {
    if (checkboxesPerspiration[i].checked) {
        checkboxCheckedPerspiration = true;
        break;
    }
}
if (!checkboxCheckedPerspiration) {
    alert("Please select at least one checkbox option for Perspiration.");
    return false;
}

// Rheatandcold
var checkboxCheckedRheatandcold = false;
var checkboxesRheatandcold = document.getElementsByName("Rheatandcold[]");
for (var i = 0; i < checkboxesRheatandcold.length; i++) {
    if (checkboxesRheatandcold[i].checked) {
        checkboxCheckedRheatandcold = true;
        break;
    }
}
if (!checkboxCheckedRheatandcold) {
    alert("Please select at least one checkbox option for Rheatandcold.");
    return false;
}

// Mind
var checkboxCheckedMind = false;
var checkboxesMind = document.getElementsByName("mind[]");
for (var i = 0; i < checkboxesMind.length; i++) {
    if (checkboxesMind[i].checked) {
        checkboxCheckedMind = true;
        break;
    }
}
if (!checkboxCheckedMind) {
    alert("Please select at least one checkbox option for Mind.");
    return false;
}

// Memory
var checkboxCheckedMemory = false;
var checkboxesMemory = document.getElementsByName("memory[]");
for (var i = 0; i < checkboxesMemory.length; i++) {
    if (checkboxesMemory[i].checked) {
        checkboxCheckedMemory = true;
        break;
    }
}
if (!checkboxCheckedMemory) {
    alert("Please select at least one checkbox option for Memory.");
    return false;
}

// Anxiety
var checkboxCheckedAnxiety = false;
var checkboxesAnxiety = document.getElementsByName("anxiety[]");
for (var i = 0; i < checkboxesAnxiety.length; i++) {
    if (checkboxesAnxiety[i].checked) {
        checkboxCheckedAnxiety = true;
        break;
    }
}
if (!checkboxCheckedAnxiety) {
    alert("Please select at least one checkbox option for Anxiety.");
    return false;
}

// Like Dislike
var checkboxCheckedLikeDislike = false;
var checkboxesLikeDislike = document.getElementsByName("like_dislike[]");
for (var i = 0; i < checkboxesLikeDislike.length; i++) {
    if (checkboxesLikeDislike[i].checked) {
        checkboxCheckedLikeDislike = true;
        break;
    }
}
if (!checkboxCheckedLikeDislike) {
    alert("Please select at least one checkbox option for Like Dislike.");
    return false;
}

// Your Nature
var checkboxCheckedYourNature = false;
var checkboxesYourNature = document.getElementsByName("your_nature[]");
for (var i = 0; i < checkboxesYourNature.length; i++) {
    if (checkboxesYourNature[i].checked) {
        checkboxCheckedYourNature = true;
        break;
    }
}
if (!checkboxCheckedYourNature) {
    alert("Please select at least one checkbox option for Your Nature.");
    return false;
}

// Fear Of
var checkboxCheckedFearOf = false;
var checkboxesFearOf = document.getElementsByName("fear_of[]");
for (var i = 0; i < checkboxesFearOf.length; i++) {
    if (checkboxesFearOf[i].checked) {
        checkboxCheckedFearOf = true;
        break;
    }
}
if (!checkboxCheckedFearOf) {
    alert("Please select at least one checkbox option for Fear Of.");
    return false;
}


    return true; // Form is valid
}
</script>


	<body>
	<section class="ftco-section img bg-hero" style="background-image: url(bg1a.jpg);">
	
	 
		<div class="container">
		
		<div class="row justify-content-center">
				<div class="col-md-6 text-center mb-5">
					<img src="Kanakaveda.png" alt="logo">
				</div>
			</div>
			
			<div class="row justify-content-center">
				<div class="col-lg-11">
		
					<div class="wrapper">
						<div class="row no-gutters justify-content-between">
							
							<div class="col-lg-11">
							
							
								<div class="contact-wrap w-100 p-md-5 p-4"> 
									<h3><strong>GROW WELL-Height Increasing Program</strong><span style="font-size:14px;"><br>Case Study Form</span></h3>
									
									<div id="form-message-warning" class="mb-4"></div> 
				      		<div id="form-message-success" class="mb-4">
				            Your message was sent, thank you!
				      		</div>
									  <form method="post" action="insert_case_study.php" enctype="multipart/form-data" onSubmit="return validateForm()">
							     <input type="hidden" name="appointment"  value="<?php echo $_REQUEST['appointment'];?>" /> 
								 <input type="hidden" name="username"  value="<?php echo $_REQUEST['username'];?>" /> 
								 <input type="hidden" name="password"  value="<?php echo $_REQUEST['password'];?>" />  
								 
									<label style="color:#000000">Parent Details*</label><hr>
										<div class="row">
											<div class="col-md-12">
												<div class="form-group">
													<input type="date" class="form-control" name="form_date" placeholder="Date" required>
												</div>
											</div>
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="first_name"  placeholder="First Name" required>
												</div>
											</div>
											<div class="col-md-12">
												<div class="form-group">
													<input type="text" class="form-control" name="last_name" placeholder="Last Name" required>
												</div>
											</div>
											
											<div class="col-md-12">
												<div class="form-group">
													<input type="number" class="form-control" name="mobile_no" placeholder="Mobile" required pattern="[0-9]{10}">
												</div>
											</div>
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="date" class="form-control" name="birth_date"  placeholder="Birth Date" required>
												</div>
											</div>
											
											<div class="col-md-12">
												<div class="form-group">
													<input type="number" class="form-control" name="aadhar_no" placeholder="AADHAR No." required pattern="^[1-9]{1}[0-9]{11}$">
												</div>
											</div>
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="number" class="form-control" name="child_height_inch"  placeholder="Height (In Feet / Inches)" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="number" class="form-control" name="child_height_cm"  placeholder="Height (In Cm )" required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="number" class="form-control" name="child_weight_kg"  placeholder="Weight in Kg." required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="email" class="form-control" name="email"  placeholder="Email" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="occupation"  placeholder="Occupation" required>
												</div>
											</div>
											
									  </div>
											<label style="color:#000000"><strong>Address*</strong></label><hr>
											<div class="row">
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="address1"  placeholder="Street Address" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="address2"  placeholder="Street Address Line 2" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="city"  placeholder="City" required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="state"  placeholder="State / Province" required >
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="zipcode"  placeholder="Postal / Zip Code" required  pattern="^\d{6}$">
												</div>
											</div>
											
											
											
											</div>
											
											<label style="color:#000000"><strong>Chief Complaints*</strong></label><hr>
											<div class="row">
											
											<div class="col-md-12"> 
												<div class="form-group">
													<textarea name="chief_complaints" class="form-control"  required="required"></textarea>
												</div>
											</div>
											</div>
											
											
											
											
											<label style="color:#000000"><strong>Past History of Any Disease:*</strong></label><hr>
											<div class="row">
											
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="past_history[]" id="checkbox1" value="Measles">
				<label for="checkbox1" style="color:#000000">Measles</label><br>
											
				<input type="checkbox" name="past_history[]" id="checkbox2" value="Mumps">
				<label for="checkbox2" style="color:#000000">Mumps</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox3" value="Chickenpox">
				<label for="checkbox3" style="color:#000000">Chickenpox</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Chicken Gunia">
				<label for="checkbox4" style="color:#000000">Chicken Gunia</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Maleria">
				<label for="checkbox4" style="color:#000000">Maleria</label><br>
												
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Jaundice">
				<label for="checkbox4" style="color:#000000">Jaundice</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Typhoid">
				<label for="checkbox4" style="color:#000000">Typhoid</label><br>	
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Renal Stone">
				<label for="checkbox4" style="color:#000000">Renal Stone</label><br>
				
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Gall Stone">
				<label for="checkbox4" style="color:#000000">Gall Stone</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Heart-Attack">
				<label for="checkbox4" style="color:#000000">Heart-Attack</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Piles">
				<label for="checkbox4" style="color:#000000">Piles</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="past_history_Other" placeholder="Other">
											
												
												</div></div>
												
												
											
											</div>
											
											<label style="color:#000000"><strong>Upload Reports</strong></label><hr>
											
												<div class="row">
											
										
            	 <div class="col-md-12"> 
												<div class="form-group">
				   <input type="file" class="file-form-control" name="medical_report" accept=".jpeg, .jpg, .png, .pdf, .doc, .docx">
           
          </div>  </div></div>
		  
		  <hr>
											
				<label style="color:#000000"><h3><strong>Family History</strong></h3></label><hr>							
											
												
											<div class="row">
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="father_ht_cm"  placeholder="Father's Ht (In Cm)*" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="mother_ht_cm"  placeholder="Mother's Ht (In Cm)*" required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="siblings_ht_cm"  placeholder="Siblings Ht (In Cm)*" required>
												</div>
											</div>
											</div>
											
											<label style="color:#000000"><strong>Father*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="father_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="father_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="father_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="father_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="father_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="father_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="father_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="father_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="father_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Paternal Grand Father:*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="Gfather_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="Gfather_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="Gfather_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Paternal Grand Mother: *</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="GMfather_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="GMfather_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="GMfather_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
											
											
											
											
											
										<label style="color:#000000"><strong>Mother*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="mother_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="mother_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="mother_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="mother_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="mother_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="mother_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="mother_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="mother_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="mother_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Maternal Grand Father*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="Gmother_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="Gmother_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="Gmother_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Maternal Grand Mother*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox1" value="Short stature">
				<label for="checkbox1" style="color:#000000">Short stature</label><br>
											
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox2" value="High Blood pressure">
				<label for="checkbox2" style="color:#000000">High Blood pressure</label><br>
				
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox3" value="Diabetes">
				<label for="checkbox3" style="color:#000000">Diabetes</label><br>
				
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox4" value="Heart-attack">
				<label for="checkbox4" style="color:#000000">Heart-attack</label><br>
				
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox4" value="Cancer">
				<label for="checkbox4" style="color:#000000">Cancer</label><br>
												
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox4" value="Skin Disease">
				<label for="checkbox4" style="color:#000000">Skin Disease</label><br>
				
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox4" value="Obesity">
				<label for="checkbox4" style="color:#000000">Obesity</label><br>	
				
				<input type="checkbox" name="GMmother_past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="GMmother_past_history_other" placeholder="Other">
												
												</div></div>
											
											</div>
												
											<hr>	
											
											<label style="color:#000000"><strong>Developmental History in case of Children*</strong></label><hr>	
											
											
												
											<div class="row">
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="developmental_history[]" id="checkbox1" value="Milestone Normal">
				<label for="checkbox1" style="color:#000000">Milestone Normal</label><br>
											
				<input type="checkbox" name="developmental_history[]" id="checkbox2" value="Late learning to Walk">
				<label for="checkbox2" style="color:#000000">Late learning to Walk</label><br>
				
				<input type="checkbox" name="developmental_history[]" id="checkbox3" value="Late learning to Talk">
				<label for="checkbox3" style="color:#000000">Late learning to Talk</label><br>
				
				
												
												</div></div>
											
											</div>
											
											<hr>	
											
											<label style="color:#000000"><h3><strong>Obstetric and Gynecological History </strong></h3>For Femals</strong></label><hr>	
											
											
											

											
											<label style="color:#000000"><strong>Menses</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="menses[]" id="checkbox1" value="Regular">
				<label for="checkbox1" style="color:#000000">Regular</label><br>
											
				<input type="checkbox" name="menses[]" id="checkbox2" value="Irregular">
				<label for="checkbox2" style="color:#000000">Irregular</label><br>
				
				<input type="checkbox" name="menses[]" id="checkbox3" value="Profuse with Clots">
				<label for="checkbox3" style="color:#000000">Profuse with Clots</label><br>
				
				<input type="checkbox" name="menses[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Leucorrhoea</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="leucorrhoea[]" id="checkbox1" value="YES">
				<label for="checkbox1" style="color:#000000">YES</label><br>
											
				<input type="checkbox" name="leucorrhoea[]" id="checkbox2" value="NO">
				<label for="checkbox2" style="color:#000000">NO</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="White">
				<label for="checkbox3" style="color:#000000">White</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Yellowish">
				<label for="checkbox3" style="color:#000000">Yellowish</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Greenish">
				<label for="checkbox3" style="color:#000000">Greenish</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Offensive Smell">
				<label for="checkbox3" style="color:#000000">Offensive Smell</label><br>
												
												</div></div>
											
											</div>
												
											
											
											
											
											
											
											
											
												<hr>	
											
											<label style="color:#000000"><h3><strong>Generalities</strong></h3></label><hr>	
											
											
											

											
											<label style="color:#000000"><strong>Addiction</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="addiction[]" id="checkbox1" value="Alcohol">
				<label for="checkbox1" style="color:#000000">Alcohol</label><br>
											
				<input type="checkbox" name="addiction[]" id="checkbox2" value="Tobacco">
				<label for="checkbox2" style="color:#000000">Tobacco</label><br>
				
				<input type="checkbox" name="addiction[]" id="checkbox3" value="Smoking">
				<label for="checkbox3" style="color:#000000">Smoking</label><br>
				
				<input type="checkbox" name="addiction[]" id="checkbox3" value="Gutka">
				<label for="checkbox3" style="color:#000000">Gutka</label><br>
				
				<input type="checkbox" name="addiction[]" id="checkbox2" value="Tea">
				<label for="checkbox2" style="color:#000000">Tea</label><br>
				
				<input type="checkbox" name="addiction[]" id="checkbox3" value="Coffee">
				<label for="checkbox3" style="color:#000000">Coffee</label><br>
				
				<input type="checkbox" name="addiction[]" id="checkbox3" value="Drugs">
				<label for="checkbox3" style="color:#000000">Drugs</label><br>
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Water Thirst*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="water_thirst[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="water_thirst[]" id="checkbox2" value="Absent">
				<label for="checkbox2" style="color:#000000">Absent</label><br>
				
				<input type="checkbox" name="water_thirst[]" id="checkbox3" value="At a Time Small quantity at a small interval">
				<label for="checkbox3" style="color:#000000">At a Time Small quantity at a small interval</label><br>
				
				<input type="checkbox" name="water_thirst[]" id="checkbox3" value="At a Time Large quantity Large Interval.">
				<label for="checkbox3" style="color:#000000">At a Time Large quantity Large Interval.</label><br>
				
				
												
												</div></div>
											
											</div>
												
											
											
											
											<label style="color:#000000"><strong>Desire / Likes*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="desire[]" id="checkbox1" value="Sweet">
				<label for="checkbox1" style="color:#000000">Sweet</label><br>
											
				<input type="checkbox" name="desire[]" id="checkbox2" value="Spice">
				<label for="checkbox2" style="color:#000000">Spice</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox3" value="Sore">
				<label for="checkbox3" style="color:#000000">Sore</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox4" value="Salty">
				<label for="checkbox4" style="color:#000000">Salty</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox4" value="fruits">
				<label for="checkbox4" style="color:#000000">Fruits</label><br>
												
				<input type="checkbox" name="desire[]" id="checkbox4" value="Green Vegetable">
				<label for="checkbox4" style="color:#000000">Green Vegetable</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox4" value="Bakery Products">
				<label for="checkbox4" style="color:#000000">Bakery Products</label><br>	
				
				<input type="checkbox" name="desire[]" id="checkbox1" value="Eggs">
				<label for="checkbox1" style="color:#000000">Eggs</label><br>
											
				<input type="checkbox" name="desire[]" id="checkbox2" value="Fish">
				<label for="checkbox2" style="color:#000000">Fish</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox3" value="Chicken">
				<label for="checkbox3" style="color:#000000">Chicken</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox4" value="Meat">
				<label for="checkbox4" style="color:#000000">Meat</label><br>
				
				<input type="checkbox" name="desire[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="desire_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Aversion / Don’t like*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="aversion[]" id="checkbox1" value="Sweet">
				<label for="checkbox1" style="color:#000000">Sweet</label><br>
											
				<input type="checkbox" name="aversion[]" id="checkbox2" value="Spice">
				<label for="checkbox2" style="color:#000000">Spice</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox3" value="Sore">
				<label for="checkbox3" style="color:#000000">Sore</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox4" value="Salty">
				<label for="checkbox4" style="color:#000000">Salty</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox4" value="fruits">
				<label for="checkbox4" style="color:#000000">Fruits</label><br>
												
				<input type="checkbox" name="aversion[]" id="checkbox4" value="Green Vegetable">
				<label for="checkbox4" style="color:#000000">Green Vegetable</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox4" value="Bakery Products">
				<label for="checkbox4" style="color:#000000">Bakery Products</label><br>	
				
				<input type="checkbox" name="aversion[]" id="checkbox1" value="Eggs">
				<label for="checkbox1" style="color:#000000">Eggs</label><br>
											
				<input type="checkbox" name="aversion[]" id="checkbox2" value="Fish">
				<label for="checkbox2" style="color:#000000">Fish</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox3" value="Chicken">
				<label for="checkbox3" style="color:#000000">Chicken</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox4" value="Meat">
				<label for="checkbox4" style="color:#000000">Meat</label><br>
				
				<input type="checkbox" name="aversion[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="aversion_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Appetite*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="appetite[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="appetite[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="appetite[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
				
				
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											
											
												<hr>	
											
											<label style="color:#000000"><h3><strong>Bowel Habit</strong></h3></label><hr>	
											
											
											

											
											<label style="color:#000000"><strong>Stool</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="stool[]" id="checkbox1" value="Regular">
				<label for="checkbox1" style="color:#000000">Regular</label><br>
											
				<input type="checkbox" name="stool[]" id="checkbox2" value="Insufficient">
				<label for="checkbox2" style="color:#000000">Insufficient</label><br>
				
				<input type="checkbox" name="stool[]" id="checkbox3" value="Constipation">
				<label for="checkbox3" style="color:#000000">Constipation</label><br>
				
				<input type="checkbox" name="stool[]" id="checkbox3" value="Stool with Bleeding">
				<label for="checkbox3" style="color:#000000">Stool with Bleeding</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											
												<label style="color:#000000"><strong>Urine</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="urine[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="urine[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="urine[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
				
				<input type="checkbox" name="urine[]" id="checkbox3" value="Involuntary Urination">
				<label for="checkbox3" style="color:#000000">Involuntary Urination</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											
											
												<label style="color:#000000"><strong>Sleep*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="sleep[]" id="checkbox1" value="Sound">
				<label for="checkbox1" style="color:#000000">Sound</label><br>
											
				<input type="checkbox" name="sleep[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="sleep[]" id="checkbox3" value="Insomnia">
				<label for="checkbox3" style="color:#000000">Insomnia</label><br>
				
				<input type="checkbox" name="sleep[]" id="checkbox3" value="Disturbed">
				<label for="checkbox3" style="color:#000000">Disturbed</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											<label style="color:#000000"><strong>Perspiration*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="perspiration[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="perspiration[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="perspiration[]" id="checkbox3" value="Offensive">
				<label for="checkbox3" style="color:#000000">Offensive</label><br>
				
				
				
			
												
												</div></div>
											
											</div>
											
											
											
											
												<label style="color:#000000"><strong>Relation with Heat and Cold*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="Rheatandcold[]" id="checkbox1" value="Tolerate Cold">
				<label for="checkbox1" style="color:#000000">Tolerate Cold</label><br>
											
				<input type="checkbox" name="Rheatandcold[]" id="checkbox2" value="Tolerate Heat">
				<label for="checkbox2" style="color:#000000">Tolerate Heat</label><br>
				
				<input type="checkbox" name="Rheatandcold[]" id="checkbox3" value="Can Tolerate Both">
				<label for="checkbox3" style="color:#000000">Can Tolerate Both</label><br>
				
				<input type="checkbox" name="Rheatandcold[]" id="checkbox3" value="Can not Tolerate Both">
				<label for="checkbox3" style="color:#000000">Can not Tolerate Both</label><br>
				
			
												
												</div></div>
											
											</div>
											
												
											<label style="color:#000000"><strong>Mind / Manasikta*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="mind[]" id="checkbox1" value="Sweet">
				<label for="checkbox1" style="color:#000000">Sweet</label><br>
											
				<input type="checkbox" name="mind[]" id="checkbox2" value="Spice">
				<label for="checkbox2" style="color:#000000">Spice</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox3" value="Sore">
				<label for="checkbox3" style="color:#000000">Sore</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox4" value="Salty">
				<label for="checkbox4" style="color:#000000">Salty</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox4" value="fruits">
				<label for="checkbox4" style="color:#000000">Fruits</label><br>
												
								
				<input type="checkbox" name="mind[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="mind_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
											
											<label style="color:#000000"><strong>Memory ?*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="memory[]" id="checkbox1" value="Weak">
				<label for="checkbox1" style="color:#000000">Weak</label><br>
											
				<input type="checkbox" name="memory[]" id="checkbox2" value="Medium">
				<label for="checkbox2" style="color:#000000">Medium</label><br>
				
				<input type="checkbox" name="memory[]" id="checkbox3" value="Sharp">
				<label for="checkbox3" style="color:#000000">Sharp</label><br>
				
								
				<input type="checkbox" name="memory[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="memory_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Anxiety about*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="anxiety[]" id="checkbox1" value="Health">
				<label for="checkbox1" style="color:#000000">Health</label><br>
											
				<input type="checkbox" name="anxiety[]" id="checkbox2" value="Money">
				<label for="checkbox2" style="color:#000000">Money</label><br>
				
				<input type="checkbox" name="anxiety[]" id="checkbox3" value="Future">
				<label for="checkbox3" style="color:#000000">Future</label><br>
				
				<input type="checkbox" name="anxiety[]" id="checkbox1" value="Family">
				<label for="checkbox1" style="color:#000000">Family</label><br>
											
				<input type="checkbox" name="anxiety[]" id="checkbox2" value="Children">
				<label for="checkbox2" style="color:#000000">Children</label><br>
				
				<input type="checkbox" name="anxiety[]" id="checkbox3" value="Job">
				<label for="checkbox3" style="color:#000000">Job</label><br>
				
								
				<input type="checkbox" name="anxiety[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="anxiety_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>	
											
											
											
											<label style="color:#000000"><strong>Likes / Dislikes*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="like_dislike[]" id="checkbox1" value="Music">
				<label for="checkbox1" style="color:#000000">Music</label><br>
											
				<input type="checkbox" name="like_dislike[]" id="checkbox2" value="Company with friends">
				<label for="checkbox2" style="color:#000000">Company with friends</label><br>
								
				<input type="checkbox" name="like_dislike[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="like_dislike_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Your Nature (Evaluate Your Self)*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="your_nature[]" id="checkbox1" value="Ambitious">
				<label for="checkbox1" style="color:#000000">Ambitious</label><br>
											
				<input type="checkbox" name="your_nature[]" id="checkbox2" value="History of Disappointment">
				<label for="checkbox2" style="color:#000000">History of Disappointment</label><br>
				
				<input type="checkbox" name="your_nature[]" id="checkbox1" value="History of Grief">
				<label for="checkbox1" style="color:#000000">History of Grief</label><br>
											
				<input type="checkbox" name="your_nature[]" id="checkbox2" value="Perfectionist">
				<label for="checkbox2" style="color:#000000">Perfectionist</label><br>
				
				<input type="checkbox" name="your_nature[]" id="checkbox2" value="Time Punctual">
				<label for="checkbox2" style="color:#000000">Time Punctual</label><br>

				<input type="checkbox" name="your_nature[]" id="checkbox1" value="Want Clean Everything">
				<label for="checkbox1" style="color:#000000">Want Clean Everything</label><br>
											
				<input type="checkbox" name="your_nature[]" id="checkbox2" value="Can Not Tolerate Insult">
				<label for="checkbox2" style="color:#000000">Can Not Tolerate Insult</label><br>
				
				<input type="checkbox" name="your_nature[]" id="checkbox1" value="Can Not Tolerate Injustice">
				<label for="checkbox1" style="color:#000000">Can Not Tolerate Injustice</label><br>
											
				<input type="checkbox" name="your_nature[]" id="checkbox2" value="Any Specific Mental Symptoms">
				<label for="checkbox2" style="color:#000000">Any Specific Mental Symptoms</label><br>

								
				<input type="checkbox" name="your_nature[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="your_nature_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>	
											
											
											
											<label style="color:#000000"><strong>Do you have fear of ?*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="fear_of[]" id="checkbox1" value="Darkness">
				<label for="checkbox1" style="color:#000000">Darkness</label><br>
											
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Ghost">
				<label for="checkbox2" style="color:#000000">Ghost</label><br>
				
				<input type="checkbox" name="fear_of[]" id="checkbox1" value="Height">
				<label for="checkbox1" style="color:#000000">Height</label><br>
											
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Dog">
				<label for="checkbox2" style="color:#000000">Dog</label><br>
				
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Lizard">
				<label for="checkbox2" style="color:#000000">Lizard</label><br>

				<input type="checkbox" name="fear_of[]" id="checkbox1" value="Cat">
				<label for="checkbox1" style="color:#000000">Cat</label><br>
											
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Rat">
				<label for="checkbox2" style="color:#000000">Rat</label><br>
				
				<input type="checkbox" name="fear_of[]" id="checkbox1" value="Insets">
				<label for="checkbox1" style="color:#000000">Insets</label><br>
											
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Snake">
				<label for="checkbox2" style="color:#000000">Snake</label><br>
				
				<input type="checkbox" name="fear_of[]" id="checkbox2" value="Teacher">
				<label for="checkbox2" style="color:#000000">Teacher</label><br>


								
				<input type="checkbox" name="fear_of[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="fear_of_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>	
											
											<label style="color:#000000"><strong>Upload Reports</strong></label><hr>
											
												<div class="row">
											
										
            	 <div class="col-md-12"> 
												<div class="form-group">
				   <input type="file" class="file-form-control" name="medical_report1" accept=".jpeg, .jpg, .png, .pdf, .doc, .docx">
           
          </div>  </div></div>
		  
		  <hr>
						<label style="color:#000000"><input type="checkbox" name="term_condition" id="checkbox1" value="Insets"> I agree to <a href="https://kanakavedaayurveda.com/kanakaveda-height-consent-form/" target="_blank">terms & conditions.</a> * </label>				
											  <hr>
		
		    <label for="typeahead" class="control-label" style="color:#000000">Draw Signature </label>
		<section class="signature-component">

  <canvas id="signature-pad" width="auto" height="100"></canvas>
  
 
</section>
<!-- partial -->


  <script src='https://cdnjs.cloudflare.com/ajax/libs/underscore.js/1.8.3/underscore-min.js'></script><script  src="./script.js"></script>

<!-- partial -->

				   <script>
        function saveSignature() {
            var canvas = document.getElementById('signature-pad');
            var dataURL = canvas.toDataURL(); // Get the image data

            // Send the image data to the PHP script
            var xhr = new XMLHttpRequest();
            xhr.open('POST', 'save_signature.php?name=123456', true);
            xhr.setRequestHeader('Content-type', 'application/x-www-form-urlencoded');
            xhr.onload = function() {
                if (xhr.status === 200) {
                    alert('Signature saved successfully.');
                } else {
                    alert('Failed to save signature.');
                }
            };
            xhr.send('imageData=' + encodeURIComponent(dataURL));
        }
    </script>
											
											
									
											
											
											
											<div class="col-md-12">
												<div class="form-group">
												 <input class="btn btn-success" type="submit" onClick="saveSignature()" value="Register your Program" />
													
													<div class="submitting"></div>
												</div>
											</div>
										</div>
									</form>
								</div>
							</div>
						</div>
					</div>
				</div>
			</div>
		</div>
	</section>


	<script src="js/jquery.min.js"></script>
  <script src="js/popper.js"></script>
  <script src="js/bootstrap.min.js"></script>
  <script src="js/jquery.validate.min.js"></script>
  <script src="js/main.js"></script>

	</body>
</html>

<?php } ?>