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|
<!-------------------------*QUESTION 7--------------------->
<p class="soustitrenoir">7 - Concernant ces demandes, pouvez vous renseigner le tableau suivant ? <span class="soustitrerouge">¤</span></p>
<table border="1" cellpadding="0" cellspacing="2" bgcolor="#CCCCCC">
<tr>
<td class="texte"><center><b>Numéro attribué<br> à la personne<br> (voir à la question 1) </b></center></td>
<td class="texte"><center><b>La demande a-t-elle aboutit <br> (oui/non) </center></b></td>
<td class="texte"><center><b>Si non : motif du refus évoqué par l'établissement pour personnes âgées</center></b></td>
</tr>
<!--LIGNE 1-->
<tr>
<td><textarea name="q7num_1" cols="22" rows="5 " id="num_1" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px"><?php
if (!empty($_POST["q7num_1"])) {
echo htmlspecialchars($_POST["q7num_1"],ENT_QUOTES);
}
?></textarea>
</td>
<td class="texte"> oui
<input name="q7dmd_1" type="radio" value="oui" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;font-family: Verdana; font-size:10px"<?php
if (!empty($_POST["q7dmd_1"])) {
$q7dmd_1 = $_POST["q7dmd_1"];
if ($q7dmd_1 =="oui") { echo " checked"; }
}
else {
$q7dmd_1 = "";
}
?>>
<span class="texte"> non</span>
<input name="q7dmd_1" type="radio" value="non" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px"<?php
if (!empty($_POST["q7dmd_1"])) {
$q7dmd_1 = $_POST["q7dmd_1"];
if ($q7dmd_1 =="non") { echo " checked"; }
}
else {
$q7dmd_1 = "";
}
?>></td>
<td>
<input name="q7non_1" type="checkbox" id="q7non_1" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="mq_place"<?php
if (!empty($_POST["q7non_1"])) {
$q7non_1 = $_POST["q7non_1"];
if ($q7non_1 =="mq_place") { echo " checked"; }
}
else {
$q7non_1 = "";
}
?>><span class="texte">Manque de place</span>
<br>
<input name="q7non_3" type="checkbox" id="q7non_3" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="pb_financ"<?php
if (!empty($_POST["q7non_3"])) {
$q7non_3 = $_POST["q7non_3"];
if ($q7non_3 =="pb_financ") { echo " checked"; }
}
else {
$q7non_3 = "";
}
?>><span class="texte">Problèmes financiers</span>
<br>
<input name="q7non_2" type="checkbox" id="q7non_2" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="patho"<?php
if (!empty($_POST["q7non_2"])) {
$q7non_2 = $_POST["q7non_2"];
if ($q7non_2 =="patho") { echo " checked"; }
}
else {
$q7non_2 = "";
}
?>><span class="texte">Pathologogie ou déficience incompatible avec prise en charge en maison de retraite </span>
<br>
<input name="q7non_3" type="checkbox" id="q7non_3" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="autre"<?php
if (!empty($_POST["q7non_3"])) {
$q7non_3 = $_POST["q7non_3"];
if ($q7non_3 =="autre") { echo " checked"; }
}
else {
$q7non_3 = "";
}
?>><span class="texte">Autres</span>
<span class="texte">(Préciser) :</span>
<input name="q7non_autre" type="text" id="q7non_autre" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" size="70" maxlength="70" value="<?php
if (!empty($_POST["q7non_autre"])) {
echo htmlspecialchars($_POST["q7non_autre"],ENT_QUOTES);
}
?>"></td>
</td>
</tr>
<!--LIGNE 2-->
<tr>
<td><textarea name="q7num_1" cols="22" rows="5 " id="num_1" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px"><?php
if (!empty($_POST["q7num_1"])) {
echo htmlspecialchars($_POST["q7num_1"],ENT_QUOTES);
}
?></textarea>
</td>
<td class="texte"> oui
<input name="q7dmd_1" type="radio" value="oui" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;font-family: Verdana; font-size:10px"<?php
if (!empty($_POST["q7dmd_1"])) {
$q7dmd_1 = $_POST["q7dmd_1"];
if ($q7dmd_1 =="oui") { echo " checked"; }
}
else {
$q7dmd_1 = "";
}
?>>
<span class="texte"> non</span>
<input name="q7dmd_1" type="radio" value="non" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px"<?php
if (!empty($_POST["q7dmd_1"])) {
$q7dmd_1 = $_POST["q7dmd_1"];
if ($q7dmd_1 =="non") { echo " checked"; }
}
else {
$q7dmd_1 = "";
}
?>></td>
<td>
<input name="q7non_1" type="checkbox" id="q7non_1" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="mq_place"<?php
if (!empty($_POST["q7non_1"])) {
$q7non_1 = $_POST["q7non_1"];
if ($q7non_1 =="mq_place") { echo " checked"; }
}
else {
$q7non_1 = "";
}
?>><span class="texte">Manque de place</span>
<br>
<input name="q7non_3" type="checkbox" id="q7non_3" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="pb_financ"<?php
if (!empty($_POST["q7non_3"])) {
$q7non_3 = $_POST["q7non_3"];
if ($q7non_3 =="pb_financ") { echo " checked"; }
}
else {
$q7non_3 = "";
}
?>><span class="texte">Problèmes financiers</span>
<br>
<input name="q7non_2" type="checkbox" id="q7non_2" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="patho"<?php
if (!empty($_POST["q7non_2"])) {
$q7non_2 = $_POST["q7non_2"];
if ($q7non_2 =="patho") { echo " checked"; }
}
else {
$q7non_2 = "";
}
?>><span class="texte">Pathologogie ou déficience incompatible avec prise en charge en maison de retraite </span>
<br>
<input name="q7non_3" type="checkbox" id="q7non_3" style="background-color:#000000; color:#FFFFFF; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" value="autre"<?php
if (!empty($_POST["q7non_3"])) {
$q7non_3 = $_POST["q7non_3"];
if ($q7non_3 =="autre") { echo " checked"; }
}
else {
$q7non_3 = "";
}
?>><span class="texte">Autres</span>
<span class="texte">(Préciser) :</span>
<input name="q7non_autre" type="text" id="q7non_autre" style="background-color:#FFFFFF; color:#000000; border:1px #92A6B4 solid ;
font-family: Verdana; font-size:10px" size="70" maxlength="70" value="<?php
if (!empty($_POST["q7non_autre"])) {
echo htmlspecialchars($_POST["q7non_autre"],ENT_QUOTES);
}
?>"></td>
</td>
</tr>
</table> |
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