<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Form Name</legend> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_name">Patient's Name :</label> <div class="controls"> <input id="p_name" name="p_name" type="text" placeholder="" class="input-medium" required=""> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_gender">Gender :</label> <div class="controls"> <input id="p_gender" name="p_gender" type="text" placeholder="" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_ic_pp">IC/Passport No :</label> <div class="controls"> <input id="p_ic_pp" name="p_ic_pp" type="text" placeholder="" class="input-medium" required=""> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_dob">D.O.B. :</label> <div class="controls"> <input id="p_dob" name="p_dob" type="text" placeholder="" class="input-medium"> </div> </div> <!-- Textarea --> <div class="control-group"> <label class="control-label" for="p_cd_mh">Clinic Diagnosis / Medical History :</label> <div class="controls"> <textarea id="p_cd_mh" name="p_cd_mh"></textarea> </div> </div> <!-- Textarea --> <div class="control-group"> <label class="control-label" for="p_precautions">Precautions :</label> <div class="controls"> <textarea id="p_precautions" name="p_precautions"></textarea> </div> </div> <!-- Prepended checkbox --> <div class="control-group"> <label class="control-label" for="p_acuteCare">Acute Care :</label> <div class="controls"> <div class="input-prepend"> <span class="add-on"> <label class="checkbox"> <input type="checkbox"> </label> </span> <input id="p_acuteCare" name="p_acuteCare" class="input-medium" type="text" placeholder="Shockwave Therapy"> </div> </div> </div> <!-- Multiple Checkboxes --> <div class="control-group"> <label class="control-label" for="p_exerciseTherapy">Exercise Therapy :</label> <div class="controls"> <label class="checkbox" for="p_exerciseTherapy-0"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-0" value="Soft Tissue manipulation"> Soft Tissue manipulation </label> <label class="checkbox" for="p_exerciseTherapy-1"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-1" value="Mobilization of Joints"> Mobilization of Joints </label> <label class="checkbox" for="p_exerciseTherapy-2"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-2" value="Active/Passive Mobility Exercises"> Active/Passive Mobility Exercises </label> <label class="checkbox" for="p_exerciseTherapy-3"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-3" value="Strengthening & Stretching Exercises"> Strengthening & Stretching Exercises </label> <label class="checkbox" for="p_exerciseTherapy-4"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-4" value="Spinal Exercises"> Spinal Exercises </label> <label class="checkbox" for="p_exerciseTherapy-5"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-5" value="Postural Exercises"> Postural Exercises </label> <label class="checkbox" for="p_exerciseTherapy-6"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-6" value="Stroke Physical Rehabilitation"> Stroke Physical Rehabilitation </label> <label class="checkbox" for="p_exerciseTherapy-7"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-7" value="Home Visits"> Home Visits </label> <label class="checkbox" for="p_exerciseTherapy-8"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-8" value="Manual Therapy"> Manual Therapy </label> <label class="checkbox" for="p_exerciseTherapy-9"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-9" value="Sport Physiotherapy"> Sport Physiotherapy </label> <label class="checkbox" for="p_exerciseTherapy-10"> <input type="checkbox" name="p_exerciseTherapy" id="p_exerciseTherapy-10" value="Braces & Joint Support Advice"> Braces & Joint Support Advice </label> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="textinput">Text Input</label> <div class="controls"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="input-xlarge"> <p class="help-block">help</p> </div> </div> <!-- Multiple Checkboxes --> <div class="control-group"> <label class="control-label" for="checkboxes">Muscle Reconditioning Program :</label> <div class="controls"> <label class="checkbox" for="checkboxes-0"> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="Back Reconditioning Program"> Back Reconditioning Program </label> <label class="checkbox" for="checkboxes-1"> <input type="checkbox" name="checkboxes" id="checkboxes-1" value="Shoulder Reconditioning Program"> Shoulder Reconditioning Program </label> <label class="checkbox" for="checkboxes-2"> <input type="checkbox" name="checkboxes" id="checkboxes-2" value="Knee Reconditioning Program"> Knee Reconditioning Program </label> <label class="checkbox" for="checkboxes-3"> <input type="checkbox" name="checkboxes" id="checkboxes-3" value="Follow Up Program"> Follow Up Program </label> </div> </div> <!-- Multiple Checkboxes --> <div class="control-group"> <label class="control-label" for="checkboxes">Acute Reconditioning Program : No. of Sessions</label> <div class="controls"> <label class="checkbox" for="checkboxes-0"> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="5 Sessions Program"> 5 Sessions Program </label> <label class="checkbox" for="checkboxes-1"> <input type="checkbox" name="checkboxes" id="checkboxes-1" value="10 Sessions Program"> 10 Sessions Program </label> <label class="checkbox" for="checkboxes-2"> <input type="checkbox" name="checkboxes" id="checkboxes-2" value="15 Sessions Program"> 15 Sessions Program </label> <label class="checkbox" for="checkboxes-3"> <input type="checkbox" name="checkboxes" id="checkboxes-3" value="20 Sessions Program"> 20 Sessions Program </label> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_authSpecialist">Authorized Specialist :</label> <div class="controls"> <input id="p_authSpecialist" name="p_authSpecialist" type="text" placeholder="" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="p_refClinic">Referring Clinic :</label> <div class="controls"> <input id="p_refClinic" name="p_refClinic" type="text" placeholder="" class="input-medium"> </div> </div> <!-- Button --> <div class="control-group"> <label class="control-label" for="p_send"></label> <div class="controls"> <button id="p_send" name="p_send" class="btn btn-info">Send</button> </div> </div> <!-- Prepended checkbox --> <div class="control-group"> <label class="control-label" for="p_exerciseTherapy">Exercise Therapy :</label> <div class="controls"> <div class="input-prepend"> <span class="add-on"> <label class="checkbox"> <input type="checkbox"> </label> </span> <input id="p_exerciseTherapy" name="p_exerciseTherapy" class="input-medium" type="text" placeholder="Soft Tissue Manipulation"> </div> </div> </div> </fieldset> </form>