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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<link
rel="stylesheet"
href="https://unicons.iconscout.com/release/v4.0.0/css/line.css"
/>
<title>Client Information Form</title>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap/5.3.3/css/bootstrap.min.css" integrity="sha512-jnSuA4Ss2PkkikSOLtYs8BlYIeeIK1h99ty4YfvRPAlzr377vr3CXDb7sb7eEEBYjDtcYj+AjBH3FLv5uSJuXg==" crossorigin="anonymous" referrerpolicy="no-referrer" />
<link href="assets/css/style.css" rel="stylesheet" />
</head>
<body>
<div id="bodyDiv" class="container-sm">
<h1>Client Information Form</h1>
<form>
<label for="client_name">Client Name:</label><br />
<input
type="text"
id="client_name"
name="client_name"
required
/><br /><br />
<label for="phone_number">Client Phone Number:</label><br />
<input
type="tel"
id="phone_number"
name="phone_number"
required
/><br /><br />
<label for="membership_id">Client Membership ID:</label><br />
<input
type="text"
id="membership_id"
name="membership_id"
required
/><br /><br />
<h2>Goals</h2>
<label for="goal">What are you looking for?</label><br />
<select id="goal" name="goal" required>
<option value="">Select...</option>
<option value="weight_loss">Weight Loss</option>
<option value="weight_gain">Weight Gain</option>
<option value="fat_loss">Fat Loss</option>
<option value="clean_bulking">Clean Bulking</option>
<option value="bikini">Bikini</option>
<option value="maintain">Maintain</option></select
><br /><br />
<!--
<label for="goal">Type</label><br />
<select id="m" name="ngoal" required>
<option value="">Select...</option>
<option value="weight_loss">Beginner</option>
<option value="weight_gain">Intermediate</option>
<option value="weight_gain">Advanced</option>
<option value="maintain">Novice</option></select
><br /><br />
<label for="goal">Set</label><br />
<select id="k" name="gkal" required>
<option value="">Select...</option>
<option value="weight_loss">Straight Sets</option>
<option value="weight_gain">Drop Sets</option>
<option value="fat_loss">Super Sets</option>
<option value="clean_bulking">Compound Sets</option>
<option value="bikini">Pyramid Sets</option>
<option value="bikini">Time Under Tension</option>
<option value="bikini">Tri-set/Giant Set</option>
<option value="maintain">Rest-pause Set</option></select
><br /><br />-->
<h2>Client Measurements</h2>
<label for="current_age">Current Age:</label><br />
<input
type="number"
id="current_age"
name="current_age"
required
/><br /><br />
<input
type="radio"
id="male"
name="gender"
value="male"
required
checked
/>
<label for="male">Male</label>
<input type="radio" id="female" name="gender" value="female" required />
<label for="female">Female</label>
<br /><br />
<label for="cactivity">Activity</label><br />
<select id="cactivity" name="cactivity">
<option value="1">Basal Metabolic Rate (BMR)</option>
<option value="1.2">Sedentary: little or no exercise</option>
<option value="1.375">Light: exercise 1-3 times/week</option>
<option value="1.465">Moderate: exercise 4-5 times/week</option>
<option value="1.55">
Active: daily exercise or intense exercise 3-4 times/week
</option>
<option value="1.725">
Very Active: intense exercise 6-7 times/week
</option>
<option value="1.9">
Extra Active: very intense exercise daily, or physical job
</option></select
><br /><br />
<label for="current_weight">Current Weight (in kg):</label><br />
<input
type="number"
id="current_weight"
name="current_weight"
required
/><br /><br />
<label for="current_height">Current Height (in CM):</label><br />
<input
type="number"
id="current_height"
name="current_height"
required
/><br /><br />
<div id="resultDiv">
<h3 id="resultBMI"></h3>
<canvas id="foo"></canvas>
<h3 id="youAre"></h3>
<ul>
<li>
<div id="SevereThinness"></div>
<p>Severe Thinness</p>
</li>
<li>
<div id="ModerateThinness"></div>
<p>ModerateThinness</p>
</li>
<li>
<div id="MildThinness"></div>
<p>MildThinness</p>
</li>
<li>
<div id="normal"></div>
<p>normal</p>
</li>
<li>
<div id="Overweight"></div>
<p>Overweight</p>
</li>
<li>
<div id="ObeseClass1"></div>
<p>ObeseClass1</p>
</li>
<li>
<div id="ObeseClass2"></div>
<p>Obese Class 2</p>
</li>
<li>
<div id="ObeseClass3"></div>
<p>Obese Class 3</p>
</li>
</ul>
<br />
</div>
<br />
<br /><br />
<div id="BMRTable">
<h3 id="resultBMR"></h3>
<table class="table table-bordered">
<tr>
<td>Fat</td>
<td id="fatNeeded"></td>
</tr>
<tr>
<td>Carbohydrates</td>
<td id="carbNeeded"></td>
</tr>
<tr>
<td>Protein</td>
<td id="proteinNeeded"></td>
</tr>
<tr>
<td>Actual Calorie</td>
<td id="calorieNeeded"></td>
</tr>
<tr>
<td>Total Calorie</td>
<td id="aCalorieNeeded"></td>
</tr>
</table>
</div>
<br /><br /><br />
<h2>More detailed ?</h2>
<input
type="radio"
id="detailed_yes"
name="detailedInfo"
value="yes"
required
/>
<label for="detailed_yes">Yes</label>
<input
type="radio"
id="detailed_no"
name="detailedInfo"
value="no"
required
checked
/>
<label for="detailed_no">No</label>
<br /><br />
<div id="detailedForm">
<h2>Weight History</h2>
<label for="weight_problem_start"
>When did your weight problem begin?</label
><br />
<select
id="weight_problem_start"
name="weight_problem_start"
required
>
<option value="">Select...</option>
<option value="childhood">Childhood</option>
<option value="adolescent">Adolescent</option>
<option value="teenager">Teenager</option>
<option value="10_years_ago">10 Years Ago</option>
<option value="20_years_ago">20 Years Ago</option>
<option value="30_years_ago">30 Years Ago</option>
<option value="throughout_life">Throughout Life</option>
<option value="none">None</option></select
><br /><br /><br />
<label for="weight_gain_reason"
>What do you think is reason for your weight gain?</label
><br />
<label for="weight_gain_reason" name="weight_gain_reason"></label
><br />
<input type="checkbox" id="injury" value="injury" />
<label for="injury" name="weight_gain_reason">Injury</label><br />
<input type="checkbox" id="pregnancy" value="pregnancy" />
<label for="pregnancy" name="weight_gain_reason">Pregnancy</label
><br />
<input type="checkbox" id="overeating" value="overeating" />
<label for="overeating" name="weight_gain_reason">Overeating</label
><br />
<input
type="checkbox"
id="poor_eating_habits"
value="poor_eating_habits"
/>
<label for="poor_eating_habits" name="weight_gain_reason"
>Poor Eating Habits</label
><br />
<input type="checkbox" id="heredity" value="heredity" />
<label for="heredity" name="weight_gain_reason">Heredity</label><br />
<input
type="checkbox"
id="lack_of_exercise"
value="lack_of_exercise"
/>
<label for="lack_of_exercise" name="weight_gain_reason"
>Lack of Exercise</label
><br />
<input type="checkbox" id="marriage" value="marriage" />
<label for="marriage" name="weight_gain_reason">Marriage</label><br />
<input
type="checkbox"
id="smoking_cessation"
value="smoking_cessation"
/>
<label for="smoking_cessation" name="weight_gain_reason"
>Smoking Cessation</label
><br />
<input type="checkbox" id="stress" value="stress" />
<label for="stress" name="weight_gain_reason">Stress</label><br />
<input type="checkbox" id="divorce" value="divorce" />
<label for="divorce" name="weight_gain_reason">Injury</label><br />
<br /><br />
<h2>Diet</h2>
<label for="meals_per_day">How many meals per day do you eat?</label
><br />
<select id="meals_per_day" name="meals_per_day" required>
<option value="">Select...</option>
<option value="one_meal">One Meal</option>
<option value="two_meals">Two Meals</option>
<option value="three_meals">Three Meals</option>
<option value="one_to_two_meals">One to Two Meals</option>
<option value="two_to_three_meals">Two to Three Meals</option>
<option value="three_or_more_meals">Three or More Meals</option>
<option value="none">None</option></select
><br /><br />
<label for="skipped_meal"
>If you skip meals what meal(s) do you usually skip?</label
><br />
<select id="skipped_meal" name="skipped_meal" required>
<option value="">Select...</option>
<option value="breakfast">Breakfast</option>
<option value="lunch">Lunch</option>
<option value="dinner">Dinner</option>
<option value="none">None</option></select
><br /><br />
<label for="skipped_meal_days"
>How many days a week do you skip this meal?</label
><br />
<select id="skipped_meal_days" name="skipped_meal_days" required>
<option value="">Select...</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option></select
><br /><br />
<label for="snacking_frequency">How often do you snack?</label><br />
<select id="snacking_frequency" name="snacking_frequency" required>
<option value="">Select...</option>
<option value="am_snack">A.M. Snack</option>
<option value="pm_snack">P.M. Snack</option>
<option value="evening_snack">Evening Snack</option>
<option value="between_meals">Snack Between All Meals</option>
<option value="grazing">Grazing on Food Throughout the Day</option>
<option value="none">None</option></select
><br /><br />
<label for="non_veg">Non-Veg Intake:</label><br />
<select id="non_veg" name="non_veg" required>
<option value="">Select...</option>
<option value="daily">Daily</option>
<option value="twice_weekly">Weekly Twice</option>
<option value="sunday">Sundays Only</option>
<option value="none">None</option></select
><br /><br />
<label for="veg">Veg Intake:</label><br />
<select id="veg" name="veg" required>
<option value="">Select...</option>
<option value="daily">Daily</option>
<option value="twice_weekly">Weekly Twice</option>
<option value="sunday">Sundays Only</option></select
><br /><br />
<label for="egg">Egg Intake:</label><br />
<select id="egg" name="egg" required>
<option value="">Select...</option>
<option value="daily">Daily</option>
<option value="none">None</option>
<option value="twice_weekly">Weekly Twice</option>
<option value="sunday">Sundays Only</option></select
><br /><br />
<label for="alcohol">Do you drink alcohol?</label><br />
<input
type="radio"
id="alcohol_yes"
name="alcohol"
value="yes"
required
/>
<label for="alcohol_yes">Yes</label>
<input
type="radio"
id="alcohol_no"
name="alcohol"
value="no"
required
/>
<label for="alcohol_no">No</label><br /><br />
<label for="smoking">Do you smoke?</label><br />
<input
type="radio"
id="smoking_yes"
name="smoking"
value="yes"
required
/>
<label for="smoking_yes">Yes</label>
<input
type="radio"
id="smoking_no"
name="smoking"
value="no"
required
/>
<label for="smoking_no">No</label><br />
<h2>Health Conditions</h2>
<label for="diabetes">Diabetes:</label><br />
<input
type="radio"
id="diabetes_yes"
name="diabetes"
value="yes"
required
/>
<label for="diabetes_yes">Yes</label>
<input
type="radio"
id="diabetes_no"
name="diabetes"
value="no"
required
/>
<label for="diabetes_no">No</label><br /><br />
<label for="cardiovascular">Cardiovascular:</label><br />
<input
type="radio"
id="cardiovascular_yes"
name="cardiovascular"
value="yes"
required
/>
<label for="cardiovascular_yes">Yes</label>
<input
type="radio"
id="cardiovascular_no"
name="cardiovascular"
value="no"
required
/>
<label for="cardiovascular_no">No</label><br /><br />
<label for="thyroid_problems">Thyroid Problems:</label><br />
<input
type="radio"
id="thyroid_problems_yes"
name="thyroid_problems"
value="yes"
required
/>
<label for="thyroid_problems_yes">Yes</label>
<input
type="radio"
id="thyroid_problems_no"
name="thyroid_problems"
value="no"
required
/>
<label for="thyroid_problems_no">No</label><br /><br />
<label for="respiratory">Respiratory:</label><br />
<input
type="radio"
id="respiratory_yes"
name="respiratory"
value="yes"
required
/>
<label for="respiratory_yes">Yes</label>
<input
type="radio"
id="respiratory_no"
name="respiratory"
value="no"
required
/>
<label for="respiratory_no">No</label><br /><br />
<h2>Family Health History</h2>
<br />
<label for="diabetes_fam">Diabetes:</label><br />
<input
type="checkbox"
name="parents"
id="parentsD"
value="parents"
required
/>
<label for="parentsD">Parents</label>
<br />
<input
type="checkbox"
name="Grandparents"
id="GrandparentsD"
value="Grandparents"
required
/>
<label for="GrandparentsD">Grand Parents</label><br />
<input
type="checkbox"
id="BrothersD"
name="brothersD"
value="parents"
required
/>
<label for="BrothersD">Brothers</label><br />
<input
type="checkbox"
id="SisterD"
name="SisterD"
value="no"
required
/>
<label for="SisterD">Sisters</label><br /><br />
<label for="cardiovascular">Cardiovascular:</label><br />
<input
type="checkbox"
name="parents"
id="parentsC"
value="parents"
required
/>
<label for="parentsC">Parents</label><br />
<input
type="checkbox"
name="GrandparentsC"
id="GrandparentsC"
value="Grandparents"
required
/>
<label for="GrandparentsC">Grand Parents</label><br />
<input
type="checkbox"
id="BrothersC"
name="brothersC"
value="parents"
required
/>
<label for="BrothersC">Brothers</label>
<br />
<input
type="checkbox"
id="SisterC"
name="SisterC"
value="Sister"
required
/>
<label for="SisterC">Sisters</label>
<br /><br /><br />
<label for="respiratory">Respiratory:</label><br />
<input
type="checkbox"
name="parents"
id="parentsR"
value="parents"
required
/>
<label for="parentsR">Parents</label><br />
<input
type="checkbox"
name="GrandparentsR"
id="GrandparentsR"
value="Grandparents"
required
/>
<label for="GrandparentsR">Grand Parents</label><br />
<input
type="checkbox"
id="BrothersR"
name="brothersR"
value="parents"
required
/>
<label for="BrothersR">Brothers</label>
<br />
<input
type="checkbox"
id="SisterR"
name="SisterR"
value="Sister"
required
/>
<label for="SisterC">Sisters</label><br /><br /><br />
<fieldset id="female_questions">
<h2>Female Specific Questions</h2>
<label for="problems_conceiving">Problems Conceiving:</label><br />
<input
type="radio"
id="problems_conceiving_yes"
name="problems_conceiving"
value="yes"
/>
<label for="problems_conceiving_yes">Yes</label>
<input
type="radio"
id="problems_conceiving_no"
name="problems_conceiving"
value="no"
/>
<label for="problems_conceiving_no">No</label><br /><br />
<label for="regular_periods">Are you regular?</label><br />
<input
type="radio"
id="regular_periods_yes"
name="regular_periods"
value="yes"
/>
<label for="regular_periods_yes">Yes</label>
<input
type="radio"
id="regular_periods_no"
name="regular_periods"
value="no"
/>
<label for="regular_periods_no">No</label><br /><br />
<label for="period_pain">Any pain with period?</label><br />
<input
type="radio"
id="period_pain_yes"
name="period_pain"
value="yes"
/>
<label for="period_pain_yes">Yes</label>
<input
type="radio"
id="period_pain_no"
name="period_pain"
value="no"
/>
<label for="period_pain_no">No</label><br /><br />
<label for="urine_loss">Loss of urine:</label><br />
<input
type="radio"
id="urine_loss_yes"
name="urine_loss"
value="yes"
/>
<label for="urine_loss_yes">Yes</label>
<input
type="radio"
id="urine_loss_no"
name="urine_loss"
value="no"
/>
<label for="urine_loss_no">No</label><br /><br />
</fieldset>
</div>
<div id="dietTime">
<h2 >Diet (Food Intake)</h2>
<br />
<p>WakeUp Time: <input type="time" value="06:00" /></p>
<br />
<p>Meal 1 Time: <input type="time" value="08:30"/></p>
<br />
<p>Snack 1 Time: <input type="time" value="11:00"/></p>
<br />
<p>Meal 2 Time:<input type="time" value="13:30"/></p>
<br />
<p>Snack 2 Time: <input type="time" value="16:30"/></p>
<br />
<p>Dinner Time: <input type="time" value="20:30"/></p>
<br />
<p>Sleep Time: <input type="time" value="22:30"/></p>
<br />
<button class="btn btn-outline-light" id="timeBtn" type="button">
Set Time
</button>
</div>
<br /><br />
<div class="table-responsive">
<table id="DataTable" class="table table-bordered">
<tr class="table-dark" id="HeadingThData">
<th></th>
<th>Sunday</th>
<th>Monday </th>
<th>Tuesday</th>
<th>Wednesday</th>
<th>Thursday</th>
<th>Friday</th>
<th>Saturday</th>
</tr>
<tr id="WakeupData">
<th>WakeUp</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="Meal1Data">
<th>Meal 1</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="Snack1Data">
<th>Snack 1</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="Meal2Data">
<th>Meal 2</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="Snack2Data">
<th>Snack 2</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="Meal3Data">
<th >Meal 3</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="SleepData">
<th >Sleep</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</table>
<br><br>
<label for="wake_up_food">Wake-up:</label><br />
<input
type="search"
list="itemList"
id="wakeUp"
placeholder="Search items..."
/>
<datalist id="itemList"></datalist>
<div
id="noDate"
class="toast align-items-center text-bg-danger border-0"
role="alert"
aria-live="assertive"
aria-atomic="true"
>
<div class="d-flex">
<div id="toastBody" class="toast-body"></div>
<button
type="button"
class="btn-close btn-close-white me-2 m-auto"
data-bs-dismiss="toast"
aria-label="Close"
></button>
</div>
</div>
<button class="btn btn-outline-secondary btn-sm" id="wakeUpI">
Add Selected Item
</button>
<br />
<ul class="selectedItems" data-parent="wakeTr"></ul>
<label for="breakfast_food">Meal 1:</label><br />
<input
type="search"
list="itemList"
id="breakfast"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="breakfastI">
Add Selected Item
</button>
<br />
<ul class="selectedItems" data-parent="breakTr"></ul>
<label for="morning_snacks_food">Snack 1:</label><br />
<input
type="search"
list="itemList"
id="morningSnack"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="morningSnackI">
Add Selected Item
</button>
<br />
<ul class="selectedItems" data-parent="snackOne"></ul>
<label for="lunch_food">Meal 2:</label><br />
<input
type="search"
list="itemList"
id="lunch"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="lunchI">
Add Selected Item
</button>
<br />
<ul class="selectedItems" data-parent="lunchTr"></ul>
<label for="evening_snacks_food">Snacks 2:</label><br />
<input
type="search"
list="itemList"
id="eveningSnack"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="eveningSnackI">
Add Selected Item
</button>
<ul class="selectedItems" data-parent="snackTwo"></ul>
<label for="dinner_food">Meal 3:</label><br />
<input
type="search"
list="itemList"
id="dinner"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="dinnerI">
Add Selected Item
</button>
<ul class="selectedItems" data-parent="dinnerT"></ul>
<label for="before_sleep_food">Before Sleep:</label><br />
<input
type="search"
list="itemList"
id="beforeSleep"
placeholder="Search items..."
/>
<button class="btn btn-outline-secondary btn-sm" id="beforeSleepI">
Add Selected Item
</button>
<br />
<ul class="selectedItems" data-parent="sleepTr"></ul>
<!-- <p id="calrie"></p>-->
<br />
<br />
<br />
</div>
<div class="table-responsive">
<table id="foodTable" class="table table-bordered">
<tr class="table-dark" id="HeadingTh">
<th>
<input type="checkbox" id="Allday" value="selectAll" />
<label for="Allday">Select All</label>
</th>
<th>
<input type="checkbox" name="day" id="Sunday" value="Sunday" />
<label for="Sunday">Sunday</label>
</th>
<th>
<input type="checkbox" name="day" id="Monday" value="Monday" />
<label for="Monday">Monday </label>
</th>
<th>
<input
type="checkbox"
name="day"
id="Tuesday"
value="Tuesday"
/>
<label for="Tuesday">Tuesday</label>
</th>
<th>
<input
type="checkbox"
id="Wednesday"
name="day"
value="Wednesday"
/>
<label for="Wednesday">Wednesday</label>
</th>
<th>
<input
type="checkbox"
id="Thursday"
name="day"
value="Thursday"
/>
<label for="Thursday">Thursday</label>
</th>
<th>
<input type="checkbox" id="Friday" name="day" value="Friday" />
<label for="Friday">Friday</label>
</th>
<th>
<input
type="checkbox"
id="Saturday"
name="day"
value="Saturday"
/>
<label for="Saturday">Saturday</label>
</th>
</tr>
<tr id="wakeTr">
<th id="Wakeup">WakeUp</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="breakTr">
<th id="Meal 1">Meal 1</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="snackOne">
<th id="Snack 1">Snack 1</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="lunchTr">
<th id="Meal 2">Meal 2</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="snackTwo">
<th id="Snack 2">Snack 2</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="dinnerT">
<th id="Meal 3">Meal 3</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="sleepTr">
<th id="Sleep">Sleep</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr id="calorieRow">
<th>Total Calories</th>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>