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| Current File : /var/www/html/shardahospital.org/pdms/application/views/open-hindi-survey-feedback.php |
<div class="course-topsec slidesv">
<div class="container">
<div class="row">
<div class="col-md-12">
</div>
</div>
</div>
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 1440 60">
<path fill="currentColor" d="M0,0V60H1440V0A5771,5771,0,0,1,0,0Z"></path>
</svg>
</div>
<div class="sec-newd">
<div class="new-var">
<div class="login-logo">
<a href="<?=base_url('opensurvey/hindi/'.base64_encode($survey_id))?>"><img src="<?=base_url('assests/imgs/Sharda-Hospital-Logo.png')?>"> </a>
</div>
<form method="post" action="<?=base_url('opensurvey/hindi/'.base64_encode($survey_id))?>">
<h2><?=$record['title']?></h2>
<div class="row">
<div class="englhindi">
<span>Select Language (भाषा चुने) : </span>
<a href="<?=base_url('opensurvey/'.base64_encode($survey_id))?>"> <input type="radio" name="language" value="1" ><small> English </small> </a>
<a href="javascript:void(0)"><input type="radio" name="language" value="2" checked><small> हिन्दी </small></a>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="servayform">
<label>नाम<span style="color:#ff0000;">*</span> </label> <input type="text" placeholder="नाम...." name="full_name" id="full_name" maxlength='200' required />
</div>
</div>
<div class="col-md-3">
<div class="servayform">
<label>आयु<span style="color:#ff0000;">*</span> </label>
<select name="age" id="age" required>
<option value="">आयु चुने .... </option>
<option value="1">0 - 18 वर्ष</option>
<option value="2">18 - 30 वर्ष</option>
<option value="3">30 - 45 वर्ष</option>
<option value="4">45 - 60 वर्ष</option>
<option value="5">60+</option>
</select>
<!-- <input type="text" placeholder="Write Here...." name="age" id="age" required />-->
</div>
</div>
<div class="col-md-3">
<div class="servayform">
<label>लिंग<span style="color:#ff0000;">*</span> </label>
<select name="gender" id="gender" required>
<option value="">लिंग चुने </option>
<option value="Male">पुरुष</option>
<option value="Female">स्त्री</option>
<option value="Other">अन्य</option>
</select>
<!-- <input type="text" placeholder="Write Here...." name="gender" id="gender" />-->
</div>
</div>
<div class="col-md-7">
<div class="servayform">
<label>पता<span style="color:#ff0000;">*</span> </label> <input type="text" placeholder="पता...." name="location" id="location" maxlength='200' required />
</div>
</div>
<div class="col-md-2">
<div class="servayform">
<label>पिन कोड<span style="color:#ff0000;">*</span> </label> <input type="text" placeholder="पिन कोड...." name="pincode" id="pincode" onkeyup="this.value=this.value.replace(/[^\d]/,'')" autocomplete="off" maxlength='6' required />
</div>
</div>
<div class="col-md-3">
<div class="servayform">
<label>संपर्क नंबर<span style="color:#ff0000;">*</span> </label> <input type="text" placeholder="संपर्क नंबर...." name="contact_no" id="contact_no" onkeyup="this.value=this.value.replace(/[^\d]/,'')" autocomplete="off" maxlength="10" required />
</div>
</div>
<div class="col-md-4" style="display:none;">
<div class="servayform">
<label>तारीख<span style="color:#ff0000;">*</span> </label> <input type="date" placeholder="Write Here...." name="date" value="<?=date('Y-m-d')?>" id="date" maxlength='8' required />
</div>
</div>
<div class="clearfix"></div>
</div>
<ul class="feedback-ul surwaynew">
<?php
$i = 1;
foreach($questionListArray as $row) {
$temp .= '<li><strong>'.$i++.'.'.$row["hindi_question"].'</strong>';
$temp .= '<div class="col-md-12 labels">
<input type="hidden" name="qid[]" value="'.$row["id"].'">
<input type="hidden" name="ques_type_'.$row["id"].'" value="'.$row["type"].'">';
if($row['type'] == 'radio_opt'){
$i=0;
foreach(json_decode($row['frm_option']) as $k => $v){
$checked = ''; if($i=='0') { $checked = ' checked="" '; }
$otherKeyArray = explode(' || ', $v);
$temp .='<div class="icheck-primary">
<input type="radio" id="option_'.$k.'" name="answer['.$row['id'].']" value="'.$k.'" '.$checked.' onclick="openOtherText(\''.rtrim($otherKeyArray[0]).'\',\''.$row["id"].'\')">
<label for="option_'.$otherKeyArray[1].'">'.$v.'</label>';
if($otherKeyArray[0]=='Other'){
$temp .='<span style="display:none;" id="other_'.$row["id"].'" ><input id="other_ans_'.$row["id"].'" type="text" name="other_ans_'.$row["id"].'" value="" maxlength="150" /></span>';
}
$temp .='</div>';
$i++;
}
} else if($row['type'] == 'check_opt'){
foreach(json_decode($row['frm_option']) as $k => $v){
$temp .='<div class="icheck-primary">
<input type="checkbox" id="option_'.$k.'" name="answer['.$row['id'].'][]" value="'.$k.'" >
<label for="option_'.$k.'">'.$v.'</label>
</div>';
}
} else if($row['type'] == 'textfield_b'){
$temp .='<div class="form-group">
<input type="hidden" name="ans_id_'.$row["id"].'" value="'.$row["id"].'">
'.base64_decode($row['frm_hindi_option']).'</div>';
}
else{
$temp .='<div class="form-group">
<input type="text" name="answer['.$row['id'].']" id="" cols="30" rows="4" class="form-control" placeholder="यहाँ कुछ लिखें...">
</div>';
}
$temp .='</div></li>';
}
echo $temp;
?>
</ul>
<input type="hidden" name="survey_id" id="survey_id_new" value="<?=$survey_id?>" />
<input type="submit" class="button1" name="submit" value="Submit"/>
</form>
</div>
</div>
<script>
function openOtherText(ansVal, qid)
{
if(ansVal=='Other'){
$("#other_"+qid).show();
$("#other_ans_"+qid).val('');
} else {
$("#other_"+qid).hide();
$("#other_ans_"+qid).val('');
}
}
</script>
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