Current File : /home/inlingua/public_html/sensoriumpsychologists.com/diagnostics/admin/designs/vddl_1.php

<form method="post" onsubmit="return validate_form_1()">
<div class="col-xs-12">
		<div>
        	<select name="week" id="week" class="form-control" style="width:auto;display:inline-block;">
            	<option value="">-Select Week-</option>
            	<option value="1">1st Week</option>
            	<option value="2">2nd Week</option>
            	<option value="3">3rd Week</option>
            	<option value="4">4th Week</option>
            	<option value="5">5th Week</option>
            </select>
        	<select name="day" id="day" class="form-control" style="width:auto;display:inline-block;">
            	<option value="">-Select Day-</option>
            	<option value="1">1st Day</option>
            	<option value="2">2nd Day</option>
            	<option value="3">3rd Day</option>
            	<option value="4">4th Day</option>
            	<option value="5">5th Day</option>
            	<option value="6">6th Day</option>
            	<option value="7">7th Day</option>
            </select>
        </div>
            
          <div class="box box-primary" style="margin-top:10px;">
            <div class="box-body">
                <div class="form-group">
                	<label>Question Title</label>
                    <input type="text" name="title" id="title" class="form-control" value="INSTRUCTION : In each row, select odd one out." />
                </div>
                    <div class="form-group">
                        <label>Sub Questions</label>
                        <div style="color:#F00;">
                            Instructions:<br>
                            Write 1 option in 1 box.
                        </div>
                    </div>
                    <?php
					for($i=1;$i<=15;$i++)
					{
					?>
                    <div class="clearfix"></div>
                    <div id="question_div" style="margin-top:30px;padding-top:30px;border-top:1px dotted #333;">
                            <label>Question</label>
                        <div class="form-group">
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                                <div class="col-md-2">
                                    <input type="text" name="question_<?php echo($i);?>[]" class="form-control" />
                                </div>
                        </div>
                    </div>
                    <?php
					}
					?>
                    <div class="clearfix"></div>
            </div>
          </div>
          <!-- /.box --> 
      
          <input type="submit" class="btn btn-success" name="submit_type_3" value="Add Treatment Now" />&nbsp;
          <a href="treatment_week_day.php?code=<?php echo($_GET['code']."&std=".$_GET['std']."&month=".$_GET['month']);?>"><div class="btn btn-danger">Cancel</div></a>    
</div>
</form>
        
<script>
function validate_form_1()
{
	if($("#week").val()=="")
	{
		$("#error_msg_string_ajax").html("Error : Please select Week...");
		$("#blackout_error_ajax,#error_msg_div_ajax").css({'visibility':'visible'});
		return false;
	}
	if($("#day").val()=="")
	{
		$("#error_msg_string_ajax").html("Error : Please select Day...");
		$("#blackout_error_ajax,#error_msg_div_ajax").css({'visibility':'visible'});
		return false;
	}
	
	var ans=confirm("Add Now?");
	if(ans==true)
	{
		$("#blackout").css({'visibility':'visible'});
		return true;
	}
	else
	{
		return false;
	}
}
</script>