22 lines
1.1 KiB
PHP
Executable File
22 lines
1.1 KiB
PHP
Executable File
<form id="formData">
|
|
<legend id="titre_formData">Ajouter des données</legend>
|
|
<table class="table table-responsive table-condensed">
|
|
<tbody>
|
|
<tr>
|
|
<td width="5%" align="center" class="required">Code</td>
|
|
<td width="10%" ><INPUT class="form-control majuscule" TYPE="text" id="codeTypeAffection" NAME="codeTypeAffection" required AUTOCOMPLETE="OFF" autofocus ></td>
|
|
|
|
<td width="5%" align="center" class="required">Libellé</td>
|
|
<td width="25%" ><INPUT class="form-control majuscule" TYPE="text" id="libelle" NAME="libelle" required AUTOCOMPLETE="OFF" ></td>
|
|
|
|
<td width="10%" align="center">Libellé Eng</td>
|
|
<td width="25%" ><INPUT class="form-control majuscule" TYPE="text" id="libelleEng" NAME="libelleEng"></td>
|
|
|
|
<td width="10%" align="right">Maladie Chronique</td>
|
|
<td width="5%">
|
|
<INPUT class="form-control" TYPE="checkbox" id="maladieChronique" NAME="maladieChronique" value="1" onclick="if (this.checked) this.value=1; else this.value=0;" >
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</form> |