<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" ><a href="#"><span class="glyphicon glyphicon-edit" aria-hidden="true"></span> Anamnesa</a></li> <li role="presentation" class="active"><a href="#"><span class="glyphicon glyphicon-zoom-in" aria-hidden="true"></span> Pemeriksaan Fisik</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-zoom-in" aria-hidden="true"></span> Pemeriksaan Fisik</h3> <div class="panel panel-default"> <div class="panel-heading"> <h4>Tanda Vital</h4> </div> <div class="panel-body"> <div class="row"> <div class="col-md-6" > <div class="form-group"> <div class="input-group"> <div class="input-group-addon">TD</div> <input type="text" class="form-control" id="bloodPressureInput" placeholder="Tekanan darah"> <div class="input-group-addon">mmHg</div> </div> </div> <div class="form-group"> <div class="input-group"> <div class="input-group-addon">RR</div> <input type="text" class="form-control" id="respirationRateInput" placeholder="Kecepatan pernapasan"> <div class="input-group-addon">/menit</div> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <div class="input-group"> <div class="input-group-addon">Nadi</div> <input type="text" class="form-control" id="pulseRateInput" placeholder="Nadi"> <div class="input-group-addon">/menit</div> </div> </div> <div class="form-group"> <div class="input-group"> <div class="input-group-addon">Suhu</div> <input type="text" class="form-control" id="temperatureInput" placeholder="Suhu"> <div class="input-group-addon">°C</div> </div> </div> </div> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Status General</h4></div> <textarea class="form-control" placeholder="Deskripsi pemeriksaan kondisi umum" rows="3"></textarea> </div> <div class="panel panel-default"> <div class="panel-heading"><h4>Status Lokalis</h4></div> <textarea class="form-control" placeholder="Deskripsi pemeriksaan terkait keluhan saat ini" 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>