Toggle navigation
Bootsnipp
Bootstrap
For
CSS Frameworks
Bootstrap
Foundation
Semantic UI
Materialize
Pure
Bulma
References
CSS Reference
Tools
Community
Page Builder
Form Builder
Button Builder
Icon Search
Dan's Tools
Diff / Merge
Color Picker
Keyword Tool
Web Fonts
.htaccess Generator
Favicon Generator
Site Speed Test
Snippets
Featured
Tags
By Bootstrap Version
4.1.1
4.0.0
3.3.0
3.2.0
3.1.0
3.0.3
3.0.1
3.0.0
2.3.2
Register
Login
"Anamnesa"
Bootstrap 3.3.0 Snippet by
chocomelks
3.3.0
Preview
HTML
View Full Screen
Fork
Fork this
1.9K
 
0 Fav
Post to Facebook
Tweet this
<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 ----------> <div class="container"> <div class="row"> <div class=" well col-xs-6 col-md-3"> RM234567</br> <b>Permata Sari</b></br> 29 tahun / 23 Jan 1986 <hr> <ul class="nav nav-pills nav-stacked"> <li role="presentation"><a href="#"><span class="glyphicon glyphicon-dashboard" aria-hidden="true"></span> Dashboard</a></li> <li role="presentation" class="active"><a href="#"><span class="glyphicon glyphicon-edit" aria-hidden="true"></span> Anamnesa</a></li> <li role="presentation"><a href="#"><span class="glyphicon glyphicon-file" aria-hidden="true"></span> Rekam Medis</a></li> <li role="presentation"><a href="#"><span class="glyphicon glyphicon-eye-open" aria-hidden="true"></span> Diagnosis</a></li> <li role="presentation" ><a href="#"><span class="glyphicon glyphicon-heart" aria-hidden="true"></span> Tindakan Medis</a></li> <li role="presentation"><a href="#"><span class="glyphicon glyphicon-align-left" aria-hidden="true"></span> Hasil Radiologi</a></li> </ul> </div> <div class=" col-xs-12 col-sm-6 col-md-9"> <h3><span class="glyphicon glyphicon-heart" aria-hidden="true"></span> Anamnesa</h3> <div class="panel panel-default"> <div class="panel-heading"> <div class="row"> <div class="col-md-5"> <h4>Survey</h4> </div> <form class="form-inline"> <div class=""> <div class="form-group"> <div class="input-group"> <input type="text" class="form-control" id="weightInput" placeholder="Berat badan"> <div class="input-group-addon">kg</div> </div> </div> <div class="form-group"> <div class="input-group"> <input type="text" class="form-control" id="heightInput" placeholder="Tinggi badan"> <div class="input-group-addon">cm</div> </div> </div> </div> </form> </div> </div> <div class="row"> <div class="col-md-3" style=" margin-left: 30px;"> <div class="radio"> <label> <input type="radio" name="statsAnamnesa" id="statsAutoAnamnesa" value="autoAnamnesa" checked> Auto-anamnesa </label> </div> </div> <div class="col-md-7"> <div class="radio"> <label> <input type="radio" name="statsAnamnesa" id="statsAlloAnamnesa" value="alloAnamnesa"> Allo-anamnesa <div class="input-group"> <div class="input-group-addon">Dengan nama</div> <input type="text" class="form-control" id="anamnesaWith" placeholder="Nama"> </div> <div class="input-group"> <div class="input-group-addon">Hubungan dengan pasien</div> <input type="text" class="form-control" id="anamnesaRelation" placeholder="Hubungan"> </div> </label> </div> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Keluhan Utama</h4></div> <textarea class="form-control" placeholder="Deskripsi keluhan utama" rows="3"></textarea> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Perjalanan Penyakit</h4></div> <textarea class="form-control" placeholder="Deskripsi perjalanan penyakit" rows="3"></textarea> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Alergi</h4></div> <div class="row"> <div class="col-md-3" style=" margin-left: 30px;"> <div class="radio"> <label> <input type="radio" name="alergyOption" id="alergyNo" value="tidakAda" checked> Tidak ada </label> </div> </div> <div class="col-md-8"> <div class="radio"> <label> <input type="radio" name="alergyOption" id="alergyYes" value="ada"> Ada </label> <textarea class="form-control" placeholder="Deskripsi alergi" rows="2"></textarea> </div> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Obat yang sedang dikonsumsi</h4></div> <textarea class="form-control" placeholder="Deskripsi obat" rows="3"></textarea> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Informasi Tambahan</h4></div> <textarea class="form-control" placeholder="Informasi tambahan" rows="3"></textarea> </div> </div> </div>
Related:
See More
Free Template
Login and Register Modal
Questions / Comments:
Post
Posting Guidelines
Formatting
- Now
×
Close
Donate
BTC: 12JxYMYi6Vt3mx3hcmP3B2oyFiCSF3FhYT
ETH: 0xCD715b2E3549c54A40e6ecAaFeB82138148a6c76