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donor.html
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donor.html
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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">
<title>Donor Data Form</title>
<link rel="stylesheet" href="../static/donor-styles.css">
<link rel="preconnect" href="https://fonts.googleapis.com">
<link rel="preconnect" href="https://fonts.gstatic.com" crossorigin>
<link href="https://fonts.googleapis.com/css2?family=Montserrat:ital,wght@0,100..900;1,100..900&display=swap" rel="stylesheet">
</head>
<body>
<div class="container">
<h1>Donor Data Form</h1>
<form id="donorForm" class="form-grid" action="/donor" method="POST">
<!-- Personal Identification -->
<fieldset>
<legend>Personal Identification</legend>
<label for="donorName">Full Name:</label>
<input type="text" id="donorName" name="donorName" required>
<label for="donorDob">Date of Birth:</label>
<input type="date" id="donorDob" name="donorDob" required>
<label for="donorContact">Contact Information:</label>
<input type="tel" id="donorPhone" name="donorPhone" placeholder="Phone" required>
<input type="email" id="donorEmail" name="donorEmail" placeholder="Email" required>
<label for="donorAddress">Address:</label>
<textarea id="donorAddress" name="donorAddress" rows="3" required></textarea>
</fieldset>
<!-- Medical History -->
<fieldset>
<legend>Medical History</legend>
<label for="donorHealthStatus">Current Health Status:</label>
<textarea id="donorHealthStatus" name="donorHealthStatus" rows="3" required></textarea>
<label for="donorMedicalConditions">Past Medical Conditions:</label>
<textarea id="donorMedicalConditions" name="donorMedicalConditions" rows="3" required></textarea>
<label for="donorMedications">Medications Currently Being Taken:</label>
<textarea id="donorMedications" name="donorMedications" rows="3" required></textarea>
<label for="donorAllergies">Allergies:</label>
<textarea id="donorAllergies" name="donorAllergies" rows="3"></textarea>
<label for="donorSurgeries">History of Surgeries or Major Illnesses:</label>
<textarea id="donorSurgeries" name="donorSurgeries" rows="3"></textarea>
</fieldset>
<!-- Lifestyle Information -->
<fieldset>
<legend>Lifestyle Information</legend>
<label for="donorTravel">Recent Travel History:</label>
<textarea id="donorTravel" name="donorTravel" rows="3"></textarea>
<label for="donorRiskBehaviors">High-Risk Behaviors:</label>
<textarea id="donorRiskBehaviors" name="donorRiskBehaviors" rows="3"></textarea>
<label for="donorOccupation">Occupation:</label>
<input type="text" id="donorOccupation" name="donorOccupation">
</fieldset>
<!-- Blood Type -->
<fieldset>
<legend>Blood Type</legend>
<label for="donorBloodType">Donor’s Blood Type:</label>
<select id="donorBloodType" name="donorBloodType" required>
<option value="A+">A+</option>
<option value="A-">A-</option>
<option value="B+">B+</option>
<option value="B-">B-</option>
<option value="AB+">AB+</option>
<option value="AB-">AB-</option>
<option value="O+">O+</option>
<option value="O-">O-</option>
</select>
</fieldset>
<!-- Consent -->
<fieldset>
<legend>Consent</legend>
<label>
<input type="checkbox" name="donorConsentDonate" required> I agree to donate blood
</label>
<label>
<input type="checkbox" name="donorConsentTest" required> I consent to test my blood for infections (e.g., HIV, Hepatitis B/C)
</label>
</fieldset>
<!-- Health Screening -->
<fieldset>
<legend>Health Screening</legend>
<label for="donorVitalSigns">Vital Signs (e.g., blood pressure, temperature):</label>
<textarea id="donorVitalSigns" name="donorVitalSigns" rows="3"></textarea>
<label for="donorHemoglobin">Hemoglobin Levels:</label>
<input type="text" id="donorHemoglobin" name="donorHemoglobin">
</fieldset>
<!-- Previous Donation History -->
<fieldset>
<legend>Previous Donation History</legend>
<label for="donorPastDonations">Record of Past Donations:</label>
<textarea id="donorPastDonations" name="donorPastDonations" rows="3"></textarea>
<label for="donorReactions">Any Previous Reactions to Blood Donation:</label>
<textarea id="donorReactions" name="donorReactions" rows="3"></textarea>
</fieldset>
<button type="submit">Submit Donor Data</button>
</form>
</div>
</body>
</html>