<?php
include('includes/header.php');
?>
    <h3>Test Novel Coronavirus, Dengue, Swine Flu and Viral Fever Online</h3>
        <div class="container contact-form">
                <form action="result.php" method="post" enctype="multipart/form-data"
                    
                   <div class="row">
                        <div class="col-md-12">
                            <div id="div4" class="form-group">
                                <div class="form-group">
                                    <label style="font-weight:700;">Gender<span class="form-required">*</span></label>
                                    <select name="gender" class="form-control">
                                        <option value="" disabled selected>Select your option</option>
                                        <option value="Male">Male</option>
                                        <option value="Female">Female</option>
                                        <option value="Others">Others</option>
                                    </select>
                                </div>
                                
                                <div class="form-group">
                                    <label style="font-weight:700;">Age<span class="form-required">*</span></label>
                                    <select name="age" class="form-control">
                                    <option value="" disabled selected>Select your option</option>
                                      <option value="1-10">1-10</option>
                                      <option value="11-20">11-20</option>
                                      <option value="21-30">21-30</option>
                                      <option value="31-40">31-40</option>
                                      <option value="41-50">41-50</option>
                                      <option value="51-60">51-60</option>
                                      <option value="61-70">61-70</option>
                                      <option value="71-80">71-80</option>
                                      <option value="81-90">81-90</option>
                                      <option value="91-100">91-100</option>
                                    </select>
                                </div>
                                
                                <div class="form-group">
                                    <label style="font-weight:700;">Country<span class="form-required">*</span></label>
                                    <select name="country" class="form-control">
                                        <option value="" disabled selected>Select your option</option>
                                        <option value="Afganistan">Afghanistan</option>
                                       <option value="Albania">Albania</option>
                                       <option value="Algeria">Algeria</option>
                                       <option value="American Samoa">American Samoa</option>
                                       <option value="Andorra">Andorra</option>
                                       <option value="Angola">Angola</option>
                                       <option value="Anguilla">Anguilla</option>
                                       <option value="Antigua & Barbuda">Antigua & Barbuda</option>
                                       <option value="Argentina">Argentina</option>
                                       <option value="Armenia">Armenia</option>
                                       <option value="Aruba">Aruba</option>
                                       <option value="Australia">Australia</option>
                                       <option value="Austria">Austria</option>
                                       <option value="Azerbaijan">Azerbaijan</option>
                                       <option value="Bahamas">Bahamas</option>
                                       <option value="Bahrain">Bahrain</option>
                                       <option value="Bangladesh">Bangladesh</option>
                                       <option value="Barbados">Barbados</option>
                                       <option value="Belarus">Belarus</option>
                                       <option value="Belgium">Belgium</option>
                                       <option value="Belize">Belize</option>
                                       <option value="Benin">Benin</option>
                                       <option value="Bermuda">Bermuda</option>
                                       <option value="Bhutan">Bhutan</option>
                                       <option value="Bolivia">Bolivia</option>
                                       <option value="Bonaire">Bonaire</option>
                                       <option value="Bosnia & Herzegovina">Bosnia & Herzegovina</option>
                                       <option value="Botswana">Botswana</option>
                                       <option value="Brazil">Brazil</option>
                                       <option value="British Indian Ocean Ter">British Indian Ocean Ter</option>
                                       <option value="Brunei">Brunei</option>
                                       <option value="Bulgaria">Bulgaria</option>
                                       <option value="Burkina Faso">Burkina Faso</option>
                                       <option value="Burundi">Burundi</option>
                                       <option value="Cambodia">Cambodia</option>
                                       <option value="Cameroon">Cameroon</option>
                                       <option value="Canada">Canada</option>
                                       <option value="Canary Islands">Canary Islands</option>
                                       <option value="Cape Verde">Cape Verde</option>
                                       <option value="Cayman Islands">Cayman Islands</option>
                                       <option value="Central African Republic">Central African Republic</option>
                                       <option value="Chad">Chad</option>
                                       <option value="Channel Islands">Channel Islands</option>
                                       <option value="Chile">Chile</option>
                                       <option value="China">China</option>
                                       <option value="Christmas Island">Christmas Island</option>
                                       <option value="Cocos Island">Cocos Island</option>
                                       <option value="Colombia">Colombia</option>
                                       <option value="Comoros">Comoros</option>
                                       <option value="Congo">Congo</option>
                                       <option value="Cook Islands">Cook Islands</option>
                                       <option value="Costa Rica">Costa Rica</option>
                                       <option value="Cote DIvoire">Cote DIvoire</option>
                                       <option value="Croatia">Croatia</option>
                                       <option value="Cuba">Cuba</option>
                                       <option value="Curaco">Curacao</option>
                                       <option value="Cyprus">Cyprus</option>
                                       <option value="Czech Republic">Czech Republic</option>
                                       <option value="Denmark">Denmark</option>
                                       <option value="Djibouti">Djibouti</option>
                                       <option value="Dominica">Dominica</option>
                                       <option value="Dominican Republic">Dominican Republic</option>
                                       <option value="East Timor">East Timor</option>
                                       <option value="Ecuador">Ecuador</option>
                                       <option value="Egypt">Egypt</option>
                                       <option value="El Salvador">El Salvador</option>
                                       <option value="Equatorial Guinea">Equatorial Guinea</option>
                                       <option value="Eritrea">Eritrea</option>
                                       <option value="Estonia">Estonia</option>
                                       <option value="Ethiopia">Ethiopia</option>
                                       <option value="Falkland Islands">Falkland Islands</option>
                                       <option value="Faroe Islands">Faroe Islands</option>
                                       <option value="Fiji">Fiji</option>
                                       <option value="Finland">Finland</option>
                                       <option value="France">France</option>
                                       <option value="French Guiana">French Guiana</option>
                                       <option value="French Polynesia">French Polynesia</option>
                                       <option value="French Southern Ter">French Southern Ter</option>
                                       <option value="Gabon">Gabon</option>
                                       <option value="Gambia">Gambia</option>
                                       <option value="Georgia">Georgia</option>
                                       <option value="Germany">Germany</option>
                                       <option value="Ghana">Ghana</option>
                                       <option value="Gibraltar">Gibraltar</option>
                                       <option value="Great Britain">Great Britain</option>
                                       <option value="Greece">Greece</option>
                                       <option value="Greenland">Greenland</option>
                                       <option value="Grenada">Grenada</option>
                                       <option value="Guadeloupe">Guadeloupe</option>
                                       <option value="Guam">Guam</option>
                                       <option value="Guatemala">Guatemala</option>
                                       <option value="Guinea">Guinea</option>
                                       <option value="Guyana">Guyana</option>
                                       <option value="Haiti">Haiti</option>
                                       <option value="Hawaii">Hawaii</option>
                                       <option value="Honduras">Honduras</option>
                                       <option value="Hong Kong">Hong Kong</option>
                                       <option value="Hungary">Hungary</option>
                                       <option value="Iceland">Iceland</option>
                                       <option value="Indonesia">Indonesia</option>
                                       <option value="India">India</option>
                                       <option value="Iran">Iran</option>
                                       <option value="Iraq">Iraq</option>
                                       <option value="Ireland">Ireland</option>
                                       <option value="Isle of Man">Isle of Man</option>
                                       <option value="Israel">Israel</option>
                                       <option value="Italy">Italy</option>
                                       <option value="Jamaica">Jamaica</option>
                                       <option value="Japan">Japan</option>
                                       <option value="Jordan">Jordan</option>
                                       <option value="Kazakhstan">Kazakhstan</option>
                                       <option value="Kenya">Kenya</option>
                                       <option value="Kiribati">Kiribati</option>
                                       <option value="Korea North">Korea North</option>
                                       <option value="Korea Sout">Korea South</option>
                                       <option value="Kuwait">Kuwait</option>
                                       <option value="Kyrgyzstan">Kyrgyzstan</option>
                                       <option value="Laos">Laos</option>
                                       <option value="Latvia">Latvia</option>
                                       <option value="Lebanon">Lebanon</option>
                                       <option value="Lesotho">Lesotho</option>
                                       <option value="Liberia">Liberia</option>
                                       <option value="Libya">Libya</option>
                                       <option value="Liechtenstein">Liechtenstein</option>
                                       <option value="Lithuania">Lithuania</option>
                                       <option value="Luxembourg">Luxembourg</option>
                                       <option value="Macau">Macau</option>
                                       <option value="Macedonia">Macedonia</option>
                                       <option value="Madagascar">Madagascar</option>
                                       <option value="Malaysia">Malaysia</option>
                                       <option value="Malawi">Malawi</option>
                                       <option value="Maldives">Maldives</option>
                                       <option value="Mali">Mali</option>
                                       <option value="Malta">Malta</option>
                                       <option value="Marshall Islands">Marshall Islands</option>
                                       <option value="Martinique">Martinique</option>
                                       <option value="Mauritania">Mauritania</option>
                                       <option value="Mauritius">Mauritius</option>
                                       <option value="Mayotte">Mayotte</option>
                                       <option value="Mexico">Mexico</option>
                                       <option value="Midway Islands">Midway Islands</option>
                                       <option value="Moldova">Moldova</option>
                                       <option value="Monaco">Monaco</option>
                                       <option value="Mongolia">Mongolia</option>
                                       <option value="Montserrat">Montserrat</option>
                                       <option value="Morocco">Morocco</option>
                                       <option value="Mozambique">Mozambique</option>
                                       <option value="Myanmar">Myanmar</option>
                                       <option value="Nambia">Nambia</option>
                                       <option value="Nauru">Nauru</option>
                                       <option value="Nepal">Nepal</option>
                                       <option value="Netherland Antilles">Netherland Antilles</option>
                                       <option value="Netherlands">Netherlands (Holland, Europe)</option>
                                       <option value="Nevis">Nevis</option>
                                       <option value="New Caledonia">New Caledonia</option>
                                       <option value="New Zealand">New Zealand</option>
                                       <option value="Nicaragua">Nicaragua</option>
                                       <option value="Niger">Niger</option>
                                       <option value="Nigeria">Nigeria</option>
                                       <option value="Niue">Niue</option>
                                       <option value="Norfolk Island">Norfolk Island</option>
                                       <option value="Norway">Norway</option>
                                       <option value="Oman">Oman</option>
                                       <option value="Pakistan">Pakistan</option>
                                       <option value="Palau Island">Palau Island</option>
                                       <option value="Palestine">Palestine</option>
                                       <option value="Panama">Panama</option>
                                       <option value="Papua New Guinea">Papua New Guinea</option>
                                       <option value="Paraguay">Paraguay</option>
                                       <option value="Peru">Peru</option>
                                       <option value="Phillipines">Philippines</option>
                                       <option value="Pitcairn Island">Pitcairn Island</option>
                                       <option value="Poland">Poland</option>
                                       <option value="Portugal">Portugal</option>
                                       <option value="Puerto Rico">Puerto Rico</option>
                                       <option value="Qatar">Qatar</option>
                                       <option value="Republic of Montenegro">Republic of Montenegro</option>
                                       <option value="Republic of Serbia">Republic of Serbia</option>
                                       <option value="Reunion">Reunion</option>
                                       <option value="Romania">Romania</option>
                                       <option value="Russia">Russia</option>
                                       <option value="Rwanda">Rwanda</option>
                                       <option value="St Barthelemy">St Barthelemy</option>
                                       <option value="St Eustatius">St Eustatius</option>
                                       <option value="St Helena">St Helena</option>
                                       <option value="St Kitts-Nevis">St Kitts-Nevis</option>
                                       <option value="St Lucia">St Lucia</option>
                                       <option value="St Maarten">St Maarten</option>
                                       <option value="St Pierre & Miquelon">St Pierre & Miquelon</option>
                                       <option value="St Vincent & Grenadines">St Vincent & Grenadines</option>
                                       <option value="Saipan">Saipan</option>
                                       <option value="Samoa">Samoa</option>
                                       <option value="Samoa American">Samoa American</option>
                                       <option value="San Marino">San Marino</option>
                                       <option value="Sao Tome & Principe">Sao Tome & Principe</option>
                                       <option value="Saudi Arabia">Saudi Arabia</option>
                                       <option value="Senegal">Senegal</option>
                                       <option value="Seychelles">Seychelles</option>
                                       <option value="Sierra Leone">Sierra Leone</option>
                                       <option value="Singapore">Singapore</option>
                                       <option value="Slovakia">Slovakia</option>
                                       <option value="Slovenia">Slovenia</option>
                                       <option value="Solomon Islands">Solomon Islands</option>
                                       <option value="Somalia">Somalia</option>
                                       <option value="South Africa">South Africa</option>
                                       <option value="Spain">Spain</option>
                                       <option value="Sri Lanka">Sri Lanka</option>
                                       <option value="Sudan">Sudan</option>
                                       <option value="Suriname">Suriname</option>
                                       <option value="Swaziland">Swaziland</option>
                                       <option value="Sweden">Sweden</option>
                                       <option value="Switzerland">Switzerland</option>
                                       <option value="Syria">Syria</option>
                                       <option value="Tahiti">Tahiti</option>
                                       <option value="Taiwan">Taiwan</option>
                                       <option value="Tajikistan">Tajikistan</option>
                                       <option value="Tanzania">Tanzania</option>
                                       <option value="Thailand">Thailand</option>
                                       <option value="Togo">Togo</option>
                                       <option value="Tokelau">Tokelau</option>
                                       <option value="Tonga">Tonga</option>
                                       <option value="Trinidad & Tobago">Trinidad & Tobago</option>
                                       <option value="Tunisia">Tunisia</option>
                                       <option value="Turkey">Turkey</option>
                                       <option value="Turkmenistan">Turkmenistan</option>
                                       <option value="Turks & Caicos Is">Turks & Caicos Is</option>
                                       <option value="Tuvalu">Tuvalu</option>
                                       <option value="Uganda">Uganda</option>
                                       <option value="United Kingdom">United Kingdom</option>
                                       <option value="Ukraine">Ukraine</option>
                                       <option value="United Arab Erimates">United Arab Emirates</option>
                                       <option value="United States of America">United States of America</option>
                                       <option value="Uraguay">Uruguay</option>
                                       <option value="Uzbekistan">Uzbekistan</option>
                                       <option value="Vanuatu">Vanuatu</option>
                                       <option value="Vatican City State">Vatican City State</option>
                                       <option value="Venezuela">Venezuela</option>
                                       <option value="Vietnam">Vietnam</option>
                                       <option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option>
                                       <option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
                                       <option value="Wake Island">Wake Island</option>
                                       <option value="Wallis & Futana Is">Wallis & Futana Is</option>
                                       <option value="Yemen">Yemen</option>
                                       <option value="Zaire">Zaire</option>
                                       <option value="Zambia">Zambia</option>
                                       <option value="Zimbabwe">Zimbabwe</option>
                                       <option value="Others">Others</option>
                                       
                                    </select>
                                </div>
                                    <div style="text-align:center; margin-top:5%;">
                                        <p class="btn btn-primary" onClick="show4()">Next Step</p>
                                    </div>
                            </div>
                            
                       <div class="col-md-12">
                           <div id="div5" class="form-group" style="display:none">
                                <div class="form-group">
                                    <label style="font-weight:700;">Which of the follwing is correct for you?<span class="form-required">*</span></label>
                                </div>
                                <div class="form-group">
                                    <input type="radio" name="fever" class="select-radio" value="2" onClick="show1()">
                                    <label>General fever</label><br>
                                    
                                    <input type="radio" name="fever" class="select-radio" value="3" onClick="show1()">
                                    <label>Sudden high fever</label><br>
                                    
                                    <input type="radio" name="fever" class="select-radio" value="4" onClick="show1()">
                                    <label>Fever (not always)</label><br>
                                    
                                    <input type="radio" name="fever" class="select-radio" value="5" onClick="show1()">
                                    <label>Fever (Body temperature swings in between 99-103-degree Fahrenheit)</label><br>
                                    
                                    <input type="radio" name="fever" class="select-radio" value="nill" onClick="show5()">
                                    <label>None</label><br>
                                    
                                </div>
                            </div>
                            
                                <div id="div1" class="form-group" style="display: none; padding: 0% 3%;">
                                    <label style="font-weight:700;">Which of the following symptoms apply to you?<span class="form-required">*</span></label><br>
                                    <input type="checkbox" name="symptom1" class="form-check-input" value="1">
                                    <label class="form-check-label">Tiredness</label><br>
                                    <input type="checkbox" name="symptom2" class="form-check-input" value="1">
                                    <label class="form-check-label">General cough</label><br>
                                    <input type="checkbox" name="symptom3" class="form-check-input" value="1">
                                    <label class="form-check-label">Dry cough</label><br>
                                    <input type="checkbox" name="symptom4" class="form-check-input" value="1">
                                    <label class="form-check-label">Pain all over the body</label><br>
                                    <input type="checkbox" name="symptom5" class="form-check-input" value="1">
                                    <label class="form-check-label">Shortness of breath</label><br>
                                    <input type="checkbox" name="symptom6" class="form-check-input" value="1">
                                    <label class="form-check-label">Runny nose, Cold, Nasal congestion</label><br>
                                    <input type="checkbox" name="symptom7" class="form-check-input" value="1">
                                    <label class="form-check-label">Sore throat</label><br>
                                    <input type="checkbox" name="symptom8" class="form-check-input" value="1">
                                    <label class="form-check-label">Diarrhea</label><br>
                                    <input type="checkbox" name="symptom9" class="form-check-input" value="1">
                                    <label class="form-check-label">Chills</label><br>
                                    <input type="checkbox" name="symptom10" class="form-check-input" value="1">
                                    <label class="form-check-label">Vomitting or Nausea</label><br>
                                    <input type="checkbox" name="symptom11" class="form-check-input" value="1">
                                    <label class="form-check-label">Headache</label><br>
                                    <input type="checkbox" name="symptom12" class="form-check-input" value="1">
                                    <label class="form-check-label">Loss of appetite</label><br>
                                    <input type="checkbox" name="symptom13" class="form-check-input" value="1">
                                    <label class="form-check-label">Pain in the joints and muscles of the body</label><br>
                                    <input type="checkbox" name="symptom14" class="form-check-input" value="1">
                                    <label class="form-check-label">Mild bleeding (usually from nose and gums)</label><br>
                                    <input type="checkbox" name="symptom15" class="form-check-input" value="1">
                                    <label class="form-check-label">Rash on the skin (usually seen after 2-5 days of the fever)</label><br>
                                    <input type="checkbox" name="symptom16" class="form-check-input" value="1">
                                    <label class="form-check-label">Pain in the back of the eye</label><br>
                                    <input type="checkbox" name="symptom17" class="form-check-input" value="1">
                                    <label class="form-check-label">Watery, red eyes</label><br>
                                    <input type="checkbox" name="symptom18" class="form-check-input" value="1">
                                    <label class="form-check-label">sweating</label><br>
                                    <input type="checkbox" name="symptom19" class="form-check-input" value="1">
                                    <label class="form-check-label">Suffering from dehydration</label><br>
                                    
                                    <!--corona new -->
                                    <input type="checkbox" name="symptom20" class="form-check-input" value="1">
                                    <label class="form-check-label">Persistent pain or pressure in the chest</label><br>
                                    <input type="checkbox" name="symptom21" class="form-check-input" value="1">
                                    <label class="form-check-label">New confusion or inability to arouse</label><br>
                                    <input type="checkbox" name="symptom22" class="form-check-input" value="1">
                                    <label class="form-check-label">Bluish lips or face</label><br>
                                    
                                    <!--dengue new-->
                                    <input type="checkbox" name="symptom23" class="form-check-input" value="1">
                                    <label class="form-check-label">Easy Bruising</label><br>
                                    <input type="checkbox" name="symptom24" class="form-check-input" value="1">
                                    <label class="form-check-label">Severe abdominal pain</label><br>
                                    <input type="checkbox" name="symptom25" class="form-check-input" value="1">
                                    <label class="form-check-label">Vomiting blood, or blood in the stool</label><br>
                                    <input type="checkbox" name="symptom26" class="form-check-input" value="1">
                                    <label class="form-check-label">Rapid breathing</label><br>
                                    
                                    
                                    <div style="text-align:center; margin-top:5%;">
                                        <p class="btn btn-primary" onClick="show3()">Test of Prevention Measures</p>
                                    </div>
                                    
                                </div>

                                <div id="div3" class="form-group" style="display:none; padding: 0% 3%;">
                                    <label style="font-weight:700;">Which of the following prevention measures have you taken?<span class="form-required">*</span></label><br>
                                    <input type="checkbox" name="resistance1" class="form-check-input" value="1">
                                    <label class="form-check-label">Washing your hands regularly for 20 seconds, with soap and water or alcohol-based hand rub</label><br>
                                    <input type="checkbox" name="resistance2" class="form-check-input" value="1">
                                    <label class="form-check-label">Covering your nose and mouth with a disposable tissue or flexed elbow when you cough or sneeze</label><br>
                                    <input type="checkbox" name="resistance3" class="form-check-input" value="1">
                                    <label class="form-check-label">Avoiding close contact (1 meter or 3 feet) with people who are unwell</label><br>
                                    <input type="checkbox" name="resistance4" class="form-check-input" value="1">
                                    <label class="form-check-label">Avoiding crowded places if possible</label><br>
                                    <input type="checkbox" name="resistance5" class="form-check-input" value="1">
                                    <label class="form-check-label">Staying at home for at least 24 hours after your fever is gone.</label><br>
                                    <input type="checkbox" name="resistance6" class="form-check-input" value="1">
                                    <label class="form-check-label">Using mosquito repellent coils or sprays at your home and using mosquito net during sleeping hours (any time)</label><br>
                                    <input type="checkbox" name="resistance7" class="form-check-input" value="1">
                                    <label class="form-check-label">Using mosquito repellent cream on your skin</label><br>
                                    <input type="checkbox" name="resistance8" class="form-check-input" value="1">
                                    <label class="form-check-label">Throwing away water from old tires, cans, flower pots, coconut leftovers and any other similar places where rain water can be stored.</label><br>
                                    <input type="checkbox" name="resistance9" class="form-check-input" value="1">
                                    <label class="form-check-label">Keeping Lemongrass, Holy basil, Citronella etc. mosquito repellent type trees in home</label><br>
                                    
                                    
                                    <input type="checkbox" name="resistance10" class="form-check-input" value="1">
                                    <label class="form-check-label">Staying home and self-isolate from others in the household if you feel unwell</label><br>
                                    <input type="checkbox" name="resistance11" class="form-check-input" value="1">
                                    <label class="form-check-label">Not touching your eyes, nose, or mouth if your hands are not clean</label><br>
                                    <input type="checkbox" name="resistance12" class="form-check-input" value="1">
                                    <label class="form-check-label">Wearing a facemask if you are sick</label><br>
                                    <input type="checkbox" name="resistance13" class="form-check-input" value="1">
                                    <label class="form-check-label">Cleaning & disinfecting surfaces like tables, doorknobs, switches, handles, desks, phones, keyboards, toilets, sinks, etc. which are regularly touched by you</label><br>
                                    <input type="checkbox" name="resistance14" class="form-check-input" value="1">
                                    <label class="form-check-label">Seeking for doctor’s prescription soon if you have fever, cough and difficulty breathing</label><br>
                                    
                                    <input type="checkbox" name="resistance15" class="form-check-input" value="1">
                                    <label class="form-check-label">Being especially careful to protect yourself and other family members if someone in your home gets dengue fever</label><br>
                                    <input type="checkbox" name="resistance16" class="form-check-input" value="1">
                                    <label class="form-check-label">Going hospital immediately for tests if you develop symptoms of dengue</label><br>
                                    
                                    <input type="checkbox" name="resistance17" class="form-check-input" value="1">
                                    <label class="form-check-label">Staying at least 6 feet away from people with flu-like illness</label><br>
                                    
                                    <input type="checkbox" name="resistance18" class="form-check-input" value="1">
                                    <label class="form-check-label">Going hospital immediately for tests if you develop symptoms of dengue</label><br>
                                    
                                    
                                    <div style="margin-top: 10%;">
                                        <button class="btn btn-success" style type="submit" name="submit">Submit</button>
                                    </div>
                                </div>
                                
                                

                        </div>
                        
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include('includes/footer.php');
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