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myassist.html
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myassist.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Myassist</title>
<link rel="stylesheet" href="navbar.css">
<link rel="stylesheet" href="basic.css">
<style>
.form1{
box-sizing: border-box;
border:5px solid #97ca4e;
padding: 40px 60px;
margin: 30px 30px;
font-size: 20px;
font-weight: 500;
}
.form1 input, option, textarea{
font-size: 15px;
}
button:hover{
background-color: var(--clr-neon);
color: var(--clr-bg);
}
</style>
</head>
<body>
<header class="navheader">
<a class="logo">Breathefree</a>
<div class="menu-toggle"></div>
<nav>
<ul>
<li><a href="./index.html" >Home</a></li>
<li><a href="./aboutus.html">About Us</a></li>
<li><a href="./breathingcondition.html">Breathing Conditions</a></li>
<li><a href="./inhaler.html">Inhaler A-Z</a></li>
<li><a href="./nebulization.html">Nebulization</a></li>
<li><a href="./myassist.html" class="active">My Assist</a></li>
<li><a href="./berokzindagi.html">Berok Zindagi</a></li>
</ul>
</nav>
<div class="clearfix"></div>
</header>
<h1 class="blogs" style="font-size: 40px;"><center>My Assist</center></h1>
<img width=100% src="https://www.breathefree.com/sites/all/themes/breathfree_theme/images/inhaler-educater.jpg"/>
<h2 class="blog-samples" style="font-size: 25px; padding: 10px 10px"><center>Tell us about you</center></h2>
<form class="form1 blog-samples" target="_blank" action="https://formspree.io/f/mbjwzepw" method="POST">
<label for="f1">Select File to upload ( Only in case if you had any prior Treatment ): </label>
<input type="file" id="f1" name="file1" accept="image/jpeg.image/png"><br/><br/>
<label for="tel1">Enter your Name: </label>
<input type="text" id ="i1" name="username" placeholder="Type Your Name"><br><br>
<label for="tel1">Enter your Date Of birth: </label>
<input type="date" id ="i1" name="userage" ><br><br>
<label for="tel2">Enter contact number </label>
<input type="tel" id="cont" name="telephone2" placeholder="+91 XXXXXXXXXX" pattern ="[0-9]{3}-[0-9]{4}"><br><br>
<label for="num2">Enter your mail adress</label>
<input type="email" id="mail" name="number2" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" placeholder="E.g- [email protected]"><br/><br/>
<label for="dl1">Your city</label>
<input list="city" id="city" placeholder="Type your address">
<br/><br/>
<label for="diag">Select diagonosis</label>
<select name="diagonosis" id="sl-diag">
<option value="asthama"> ASTHAMA </option>
<option value="lung health test"> LUNG HEALTH TEST</option>
<option value="emphysema">COPD </option>
<option value="emphysema">Allergic Rhinitis</option>
<option value="emphysema">Emphysema </option>
</select><br/><br/>
<label for ="query">Enter your Query here:</label><br>
<textarea id="query" name="query" rows="5" cols="100" placeholder="Your Query goes here"></textarea><br><br>
<label for="gender">Select your gender</label>
<input type="radio" class="gender" name="gender1" value="male" checked/>Male
<input type="radio" class="gender" name="gender2" value="female"/>Female
<input type="radio" class="gender" name="gender3" value="others"/>Other
<br/><br/>
<label for="problems">Select other problems in the past (multiple selection): </label><br>
<input type="checkbox" id="ds1" value="0">
<label for="diabetes">Diabetes</label>
<input type="checkbox" id="ds2" value="1">
<label for="BP disorder">BP disorder</label>
<input type="checkbox" id="ds3" value="2">
<label for="Pneumonia">Pneumonia</label>
<input type="checkbox" id="ds4" value="3">
<label for="Others">Others</label>
<br/><br/>
<button type="submit" onclick="alert('Your Form is Submitted.')" style="font-size: 20px; margin-left: 50%; padding: 10px 10px; font-weight: 700;" class="blog-samples">SUBMIT</button>
</form>
</body>
</html>