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@@ -13,34 +13,33 @@
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<input name="weight" class="form-control" />
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</div>
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<div class="mb-2">
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- <label class="text-secondary text-sm">Weight</label>
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- <input name="weight" class="form-control" />
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+ <label class="text-secondary text-sm">Last Vitamin D</label>
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+ <input name="last_vitamin_d" class="form-control" />
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</div>
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<div class="mb-2">
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- <label class="text-secondary text-sm">Weight</label>
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- <input name="weight" class="form-control" />
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+ <label class="text-secondary text-sm">Ethnicity</label>
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+ <input name="ethnicity" class="form-control" />
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</div>
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<div class="mb-2">
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- <label class="text-secondary text-sm">Weight</label>
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- <input name="weight" class="form-control" />
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+ <label class="text-secondary text-sm">Previous Dx:</label>
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+ <input name="previous_dx" class="form-control" />
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</div>
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<div class="mb-2">
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- <label class="text-secondary text-sm">Weight</label>
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- <input name="weight" class="form-control" />
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+ <label class="text-secondary text-sm">Hypertension</label>
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+ <input name="hypertension" class="form-control" />
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</div>
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<div class="mb-2">
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- <label class="text-secondary text-sm">Weight</label>
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- <input name="weight" class="form-control" />
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+ <label class="text-secondary text-sm">Diabetes</label>
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+ <input name="diabetes" class="form-control" />
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</div>
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-
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-
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- Last Vitamin D
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- Ethnicity
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- Previous Dx:
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- Hypertension
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- Diabetes
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- COPD
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- Arthritis
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+ <div class="mb-2">
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+ <label class="text-secondary text-sm">COPD</label>
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+ <input name="copd" class="form-control" />
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+ </div>
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+ <div class="mb-2">
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+ <label class="text-secondary text-sm">Arthritis</label>
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+ <input name="arthritis" class="form-control" />
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+ </div>
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<div>
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<button submit class="btn btn-sm btn-primary mr-1">Submit</button>
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