<div class="container"> <div class="row"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Form Name</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Diagnosis">Diagnosis</label> <div class="col-md-5"> <input id="Diagnosis" name="Diagnosis" type="text" placeholder="Enter your Diagnosis" class="form-control input-md"> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="fmobility">Functional Mobility (If aids, please specify)</label> <div class="col-md-4"> <label class="checkbox-inline" for="fmobility-0"> <input type="checkbox" name="fmobility" id="fmobility-0" value="No aids"> No aids </label> <label class="checkbox-inline" for="fmobility-1"> <input type="checkbox" name="fmobility" id="fmobility-1" value="W/stick"> W/stick </label> <label class="checkbox-inline" for="fmobility-2"> <input type="checkbox" name="fmobility" id="fmobility-2" value="W/frame"> W/frame </label> <label class="checkbox-inline" for="fmobility-3"> <input type="checkbox" name="fmobility" id="fmobility-3" value="W/chair"> W/chair </label> <label class="checkbox-inline" for="fmobility-4"> <input type="checkbox" name="fmobility" id="fmobility-4" value="Crutches"> Crutches </label> <label class="checkbox-inline" for="fmobility-5"> <input type="checkbox" name="fmobility" id="fmobility-5" value="Independent"> Independent </label> <label class="checkbox-inline" for="fmobility-6"> <input type="checkbox" name="fmobility" id="fmobility-6" value="Supervision"> Supervision </label> <label class="checkbox-inline" for="fmobility-7"> <input type="checkbox" name="fmobility" id="fmobility-7" value="Assistance"> Assistance </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="transfers">Transfers</label> <div class="col-md-4"> <label class="checkbox-inline" for="transfers-0"> <input type="checkbox" name="transfers" id="transfers-0" value="Independent"> Independent </label> <label class="checkbox-inline" for="transfers-1"> <input type="checkbox" name="transfers" id="transfers-1" value="Supervision"> Supervision </label> <label class="checkbox-inline" for="transfers-2"> <input type="checkbox" name="transfers" id="transfers-2" value="Assistance"> Assistance </label> <label class="checkbox-inline" for="transfers-3"> <input type="checkbox" name="transfers" id="transfers-3" value="Transfer belt"> Transfer belt </label> <label class="checkbox-inline" for="transfers-4"> <input type="checkbox" name="transfers" id="transfers-4" value="Sliding Board"> Sliding Board </label> <label class="checkbox-inline" for="transfers-5"> <input type="checkbox" name="transfers" id="transfers-5" value="Standing hoist/ Arjo"> Standing hoist/ Arjo </label> <label class="checkbox-inline" for="transfers-6"> <input type="checkbox" name="transfers" id="transfers-6" value="Sling hoist"> Sling hoist </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="seating">Seating</label> <div class="col-md-4"> <label class="checkbox-inline" for="seating-0"> <input type="checkbox" name="seating" id="seating-0" value="Independent"> Independent </label> <label class="checkbox-inline" for="seating-1"> <input type="checkbox" name="seating" id="seating-1" value="Pillows"> Pillows </label> <label class="checkbox-inline" for="seating-2"> <input type="checkbox" name="seating" id="seating-2" value="Rehab chair"> Rehab chair </label> <label class="checkbox-inline" for="seating-3"> <input type="checkbox" name="seating" id="seating-3" value="Supervision"> Supervision </label> <label class="checkbox-inline" for="seating-4"> <input type="checkbox" name="seating" id="seating-4" value="Tilt in space w/chair"> Tilt in space w/chair </label> <label class="checkbox-inline" for="seating-5"> <input type="checkbox" name="seating" id="seating-5" value="Other"> Other </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="dominantul">Dominant Upper Limb</label> <div class="col-md-4"> <label class="checkbox-inline" for="dominantul-0"> <input type="checkbox" name="dominantul" id="dominantul-0" value="Right"> Right </label> <label class="checkbox-inline" for="dominantul-1"> <input type="checkbox" name="dominantul" id="dominantul-1" value="Left"> Left </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="affectedul">Affected Upper Limb</label> <div class="col-md-4"> <label class="checkbox-inline" for="affectedul-0"> <input type="checkbox" name="affectedul" id="affectedul-0" value="Right"> Right </label> <label class="checkbox-inline" for="affectedul-1"> <input type="checkbox" name="affectedul" id="affectedul-1" value="Left"> Left </label> <label class="checkbox-inline" for="affectedul-2"> <input type="checkbox" name="affectedul" id="affectedul-2" value="Splints"> Splints </label> <label class="checkbox-inline" for="affectedul-3"> <input type="checkbox" name="affectedul" id="affectedul-3" value="NA"> NA </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="affectedll">Affected Lower Limb</label> <div class="col-md-4"> <label class="checkbox-inline" for="affectedll-0"> <input type="checkbox" name="affectedll" id="affectedll-0" value="Right"> Right </label> <label class="checkbox-inline" for="affectedll-1"> <input type="checkbox" name="affectedll" id="affectedll-1" value="Left"> Left </label> <label class="checkbox-inline" for="affectedll-2"> <input type="checkbox" name="affectedll" id="affectedll-2" value="Splints"> Splints </label> <label class="checkbox-inline" for="affectedll-3"> <input type="checkbox" name="affectedll" id="affectedll-3" value="NA"> NA </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="process-skills">Process Skills</label> <div class="col-md-4"> <label class="checkbox-inline" for="process-skills-0"> <input type="checkbox" name="process-skills" id="process-skills-0" value="Independent"> Independent </label> <label class="checkbox-inline" for="process-skills-1"> <input type="checkbox" name="process-skills" id="process-skills-1" value="Verbal prompts"> Verbal prompts </label> <label class="checkbox-inline" for="process-skills-2"> <input type="checkbox" name="process-skills" id="process-skills-2" value="Set up of task required"> Set up of task required </label> <label class="checkbox-inline" for="process-skills-3"> <input type="checkbox" name="process-skills" id="process-skills-3" value="Demonstration"> Demonstration </label> <label class="checkbox-inline" for="process-skills-4"> <input type="checkbox" name="process-skills" id="process-skills-4" value="Physical prompts"> Physical prompts </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="communication">Communication</label> <div class="col-md-4"> <label class="checkbox-inline" for="communication-0"> <input type="checkbox" name="communication" id="communication-0" value="Within normal limits"> Within normal limits </label> <label class="checkbox-inline" for="communication-1"> <input type="checkbox" name="communication" id="communication-1" value="Cognitive communication changes"> Cognitive communication changes </label> <label class="checkbox-inline" for="communication-2"> <input type="checkbox" name="communication" id="communication-2" value="Reduced intelligibility"> Reduced intelligibility </label> <label class="checkbox-inline" for="communication-3"> <input type="checkbox" name="communication" id="communication-3" value="Aphasic"> Aphasic </label> </div> </div> <!-- Multiple Checkboxes --> <div class="form-group"> <label class="col-md-4 control-label" for="Aphasic">Aphasic</label> <div class="col-md-4"> <div class="checkbox"> <label for="Aphasic-0"> <input type="checkbox" name="Aphasic" id="Aphasic-0" value="Understanding"> Understanding </label> </div> <div class="checkbox"> <label for="Aphasic-1"> <input type="checkbox" name="Aphasic" id="Aphasic-1" value="Expressing"> Expressing </label> </div> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="precautions">Precautions</label> <div class="col-md-4"> <textarea class="form-control" id="precautions" name="precautions">Infection control precautions, severe inattention, impulsive, falls risk, visual/cognitive impairment</textarea> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="addlinfo">Additional Information</label> <div class="col-md-4"> <textarea class="form-control" id="addlinfo" name="addlinfo"></textarea> </div> </div> </fieldset> </form> </div> </div>