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{% extends "public/templates/public_template.html"%} {%import "macros/input_macros.html" as im %} {% block title%}Survey Links{%endblock%} {%block main%} <div class="container"> <div class="row"> <div class="col-md-4"> {{ im.input(label="Child's MRN", type="onlyNumberKey" , name="MRN", placeholder=" 0000-0000")}} {{ im.input(label="Child's Firstname", type="text", name="FN", placeholder="Firstname:")}} {{ im.input(label="Child's Lastname", type="text", name="LN", placeholder="Lastname:")}} {{ im.input(label="Child's Date of birth", type="date", name="DOB", placeholder="Date of birth:")}} <br /> <label for="Version" id="apptLabel">Questionnaire(DQ) Type: <form method="post" id="multiple_select_form"> <select name="DQ Type" id="Version" class="form-control selectpicker" data-live-serach="true"> <option value="1" selected>Neuropsychology Full</option> <option value="2">Neuropsychology Update</option> <option value="3">Parent Rating Scales</option> <option value="4">CDL Full</option> <option value="5">CDL Update</option> <option value="6">PMHP Full</option> <option value="7">PMHP Update</option> <option value="8">Speech Full</option> <option value="10">CMO Full</option> <option value="11">CMO Update</option> <option value="12">Teacher Questionnaire</option> </select> </form> <br /> <input type="submit" name="Generate Link" class="btn btn-info" value="Generate Link" /> <br /> <br /> <label>Personalized Questionnaire Link </div> </div> {%endblock%}