Untitled

{% 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%}