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index3.html
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index3.html
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<!DOCTYPE html>
<html lang="en-in">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="icon" type="image/x-icon" href="logo.png">
<link rel="stylesheet" href="style.css">
<title>911 Dispatch</title>
</head>
<body>
<div class="container">
<form action="index4.html">
<div class="row">
<div class="col-25">
<label for="fname">condition is: </label>
</div>
<div class="col-75">
<select id="options" name="options" required>
<option value="unconcious">Obviously NOT BREATHING & Unconcious (non-traum)</option>
<option value="choke">Verified Choking - COMPLETE obstruction</option>
<option value="hang">Hanging</option>
<option value="strangulate">Strangulation (no assailant involved)</option>
<option value="suffocate">Suffocation</option>
<option value="underwater-domestic">Underwater (DOMESTIC rescue)</option>
<option value="underwater-specialized">Underwater (SPECIALIZED rescue)</option>
<option value="sinking-vechile">Sinking vechile - Caller inside</option>
<option value="vechile-floodwater">Vechile in floodwater - Caller inside</option>
<option value="pregnancy">Pregnancy / Childbirth / Miscarriage</option>
<option value="preganacy-nocontractions">Pregnancy problem (no contractions or birth)</option>
<option value="others">Others(If yes, then please sepcify in the box below.)</option>
</select><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="others">Others: </label>
</div>
<div class="col-75">
<textarea id="comment" name="comment" required></textarea>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="physical-pressense"><b>With patient now: </b></label>
</div>
<div class="col-75">
<input type="text" required><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="no-hurt"><b>Number of hurt/sick is: </b></label>
</div>
<div class="col-75">
<input type="text" required><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="age-patient"><b>How old is the patient: </b></label>
</div>
<div class="col-75">
<input type="text" required><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="gender-patient"><b>Patient's gender is: </b></label>
</div>
<div class="col-75">
<input type="text" required><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="breathing-status"><b>Is he breathing?: </b></label>
</div>
<div class="col-75">
<select id="options" name="options" required>
<option value="yes">Yes</option>
<option value="no">No</option>
<option value="unknown">Unknown (3rd/4th party)</option>
<option value="uncertain">UNCERTAIN (2nd party)</option>
<option value="ineffective">INEFFECTIVE/AGONAL</option>
</select><br>
</div>
</div>
<div class="row">
<div class="col-25">
<label for="chief-complaint-code"><b>Chief Complaint Code?: </b></label>
</div>
<div class="col-75">
<select id="options" name="options" required>
<option value="unconcious">Obviously NOT BREATHING & Unconcious (non-traum)</option>
<option value="choke">Verified Choking - COMPLETE obstruction</option>
<option value="hang">Hanging</option>
<option value="strangulate">Strangulation (no assailant involved)</option>
<option value="suffocate">Suffocation</option>
<option value="underwater-domestic">Underwater (DOMESTIC rescue)</option>
<option value="underwater-specialized">Underwater (SPECIALIZED rescue)</option>
<option value="sinking-vechile">Sinking vechile - Caller inside</option>
<option value="vechile-floodwater">Vechile in floodwater - Caller inside</option>
<option value="pregnancy">Pregnancy / Childbirth / Miscarriage</option>
<option value="preganacy-nocontractions">Pregnancy problem (no contractions or birth)</option>
<option value="others">Others(If yes, then please sepcify in the box below.)</option>
</select><br>
</div>
<div class="row">
<div class="col-25">
<label for="others">Others: </label>
</div>
<div class="col-75">
<textarea id="comment" name="comment" required></textarea>
</div>
</div>
<input type="submit" value="Submit">
</form>
</div>
</body>
</html>