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edit-personal-info.php
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<?php
include 'header.php';
var_dump($_POST);
?>
<div class="container content">
<div class="panel panel-default">
<div class="panel-body" style="padding:0 55px;">
<span><h3><b>Edit Personal Record</b></h3></span>
<p>of <b>First Last Name</b></p> <br>
<p> go to <a href="medical-history.php">Edit Patient Medical History</a></p>
<hr style="width: 98%;">
<div class="row">
<form action="<?php $_SERVER['PHP_SELF']; ?>" method="post">
<div class="form-group">
<div class="col-md-3">
<label>First Name</label>
<input type="text" class="form-control" name="firstName" placeholder="First Name">
</div>
<div class="col-md-3">
<label>Middle Name</label>
<input type="text" class="form-control" name="middleName" placeholder="Middle Name">
</div>
<div class="col-md-3">
<label>Last Name</label>
<input type="text" class="form-control" name="lastName" placeholder="Last Name">
</div>
<div class="col-md-3">
<label>Maiden Name</label>
<input type="text" class="form-control" name="maidenName" placeholder="Maiden Name">
</div>
</div>
<div class="form-group">
<div class="col-md-6">
<label>Email</label>
<input type="text" class="form-control" name="email" placeholder="Email">
</div>
<div class="col-md-6">
<label>TRN</label>
<input type="text" class="form-control" name="trn" placeholder="TRN">
</div>
</div>
<div class="form-group">
<div class="col-md-12 col-xs-12">
<label><h5>Address</h5></label>
</div>
<div class="col-md-6">
<label>Street Name</label>
<input type="text" class="form-control" name="address" placeholder="Street Name">
</div>
<div class="col-md-6">
<label>Parish</label>
<input type="text" class="form-control" name="parish" placeholder="Parish">
</div>
</div>
<div class="form-group">
<div class="col-md-12 col-xs-12">
<label><h5>Emergency Contact</h5></label>
</div>
<div class="col-md-4 col-xs-12">
<label>Next of Kin</label>
<input type="text" class="form-control" name="kin" placeholder="Next of Kin">
</div>
<div class="col-md-4 col-xs-12">
<label>Relationship</label>
<input type="text" class="form-control" name="relationship" placeholder="Relationship" >
</div>
<div class="col-md-4 col-xs-12">
<label>Tel No</label>
<input type="tel" class="form-control" name="em_telephone" placeholder="Tel No.">
</div>
</div>
<div class="form-group">
<div class="col-md-12 col-xs-12">
<label><h5>Employment Info</h5></label>
</div>
<div class="col-md-12 col-xs-4">
<input type="text" class="form-control" name="employer_name" placeholder="Name of Employer">
</div>
<div class="col-md-8 col-xs-4">
<input type="address" class="form-control" name="emp_address" placeholder="Address (Street Name)">
</div>
<div class="col-md-4 col-xs-4">
<input type="text" class="form-control" name="emp_parish" placeholder="Parish" >
</div>
</div>
<br><br>
<div class="form-group">
<div class="col-md-3" style="margin-bottom: 30px;margin-top: 30px;">
<button type="submit" class="btn btn-submit-rq">Update Personal Info</button>
</div>
</div>
<br><br>
</form>
</div>
</div>
</div>
</div>
<?php include 'footer.php' ?>
<script>
$('td').attr('contenteditable',true);
</script>