require 'db.php'; // print_r($_POST); global $mysqli; extract($_POST); if (isset($name)){ $mysqli->query("INSERT INTO `survey`(`id`, `name`, `age`, `bmi`, `sleeping_hours`, `weight`, `height`, `vf`, `bf`, `gender`, `bp`, `RBSFBS`, `hb`, `cholesterol`, `bun`, `t3`, `t4`, `tsh`, `physicalactivitylevel`, `apetite`, `nausea`, `diarrhea`, `constipation`, `pale`, `lossofappetite`, `insomnia`, `Fatigue`, `Allergy`, `Intolerance`) VALUES (NULL,'$name','$age','$bmi','$sleeping_hours','$weight','$height','$vf','$bf','$gender','$bp','$RBSFBS','$hb','$cholesterol','$bun','$t3','$t4','$tsh','$physicalactivitylevel','$apetite','$nausea','$diarrhea','$constipation','$pale','$lossofappetite','$insomnia','$Fatigue','$Allergy','$Intolerance')"); header('Location:/form/index.php?success'); } ?> Assessment Form

Assessment Form

General Information






Gender

Male Female other

Biochemical Findings



Clinical Sympotoms/Findings

Physical Activity Level:


Apetite:

Nausea YES No
Diarrhea Yes No
Constipation Yes No
Fatigue YES No
Pale YES No
Loss Of Appetite Yes No
Constipation Yes No
Allergy Yes No
Pale YES No
Loss Of Appetite Yes No
Insomnia Yes No
Intolerance Yes No