</label> <label class="radio-inline"> <input type="radio" name="ethnicity-options" id="black" value="BLACK" <?php print_field_checked('ethnicity', 'BLACK'); ?> > Black / African American </label> <label class="radio-inline"> <input type="radio" name="ethnicity-options" id="latino" value="LATINO" <?php print_field_checked('ethnicity', 'LATINO'); ?> > Hispanic / Latino </label> <label class="radio-inline"> <input type="radio" name="ethnicity-options" id="asian" value="ASIAN" <?php print_field_checked('ethnicity', 'ASIAN'); ?> > Asian / Pacific Islander </label> </div> <!-- Submit button --> <br> <div style="text-align:center"> <button type="submit" class="btn btn-info">Submit</button> </div> </form> <!-- End form --> <br> <br>
print_field_checked('lower_result', 'Resolved'); ?> >Resolved</label> <label> <input type="radio" name="lowerextremityresult" value="Improved" <?php print_field_checked('lower_result', 'Improved'); ?> >Improved</label> <label> <input type="radio" name="lowerextremityresult" value="Unchanged" <?php print_field_checked('lower_result', 'Unchanged'); ?> >Unchanged</label> <label> <input type="radio" name="lowerextremityresult" value="Worsened" <?php print_field_checked('lower_result', 'Worsened'); ?> >Worsened</label> </div> </td> </tr> </tr> </tbody> </table> </div> </div> <!-- Notes Tab --> <div id="notes" class="tab-pane fade"> <div class="form-group" align="center"> <label for="notes">NOTES:</label>
required <?php print_field_checked('heard_about_clinic', 'family-friend'); ?> > Family/Friend </label> <label class="radio-inline"> <input type="radio" name="hear-about" id="doctor" value="doctor" onclick="disableOtherField()" required <?php print_field_checked('heard_about_clinic', 'doctor'); ?> > Doctor </label> <label class="radio-inline"> <input type="radio" name="hear-about" id="other" value="other" onclick="enableOtherField()" required <?php print_field_checked('heard_about_clinic', 'other'); ?> > Other </label> <input type="text" class="form-control" id="other-explanation" name="other-explanation" placeholder="If other, explain" style="width: 500px;" disabled <?php print_field('heard_about_clinic'); ?> > </div> <!-- Submit button --> <br>