Quiz 1 PWeb
Nethaneel Patricio Linggar
5025201180
PWeb C
Quiz 1 PWeb
Pada kuis pertama kelas Pemograman Web, saya telah membuat form pendaftaran pasien menggunakan HTML, CSS, dan JS.
Source code:
index.html
<!DOCTYPE html>
<html>
<head>
<title>Formulir Pendaftaran Pasien Baru</title>
<link href="https://fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.5.0/css/all.css" integrity="sha384-B4dIYHKNBt8Bc12p+WXckhzcICo0wtJAoU8YZTY5qE0Id1GSseTk6S+L3BlXeVIU" crossorigin="anonymous">
<link rel="stylesheet" href="stylesheet.css">
</head>
<body>
<div class="testbox">
<form action="/">
<div class="banner">
<h1>FORMULIR PENDAFTARAN PASIEN BARU <span>RSUD AROSUKA</span></h1>
</div>
<div class="announcement">
<h4>PERHATIAN: HARAP MENGISI FORMULIR INI DENGAN LENGKAP DAN JELAS</h4>
</div>
<fieldset>
<legend>Identitas Pasien</legend>
<div class="item">
<label for="name">Nama Pasien<span>*</span></label>
<input id="name" type="text" name="name" required/>
</div>
<div class="item">
<label for="bplace">Tempat Lahir<span>*</span></label>
<input id="bplace" type="text" name="bplace" required/>
</div>
<div class="item">
<label for="bdate">Tanggal Lahir<span>*</span></label>
<input id="bdate" type="date" name="bdate" required/>
<i class="fas fa-calendar-alt"></i>
</div>
<div class="item">
<p>Jenis Kelamin</p>
<select>
<option selected value="" disabled selected></option>
<option value="p">Pria</option>
<option value="w">Wanita</option>
<option value="l">Lainnya</option>
</select>
</div>
<div class="item">
<label for="address">Alamat<span>*</span></label>
<textarea id="address" rows="2" required></textarea>
</div>
<div class="column">
<div class="item">
<label for="rt">RT<span>*</span></label>
<input id="rt" type="number" name="rt" required/>
</div>
<div class="item">
<label for="rw">RW<span>*</span></label>
<input id="rw" type="number" name="rw" required/>
</div>
</div>
<div class="item">
<label for="address">Provinsi<span>*</span></label>
<input id="address" type="text" name="address" required/>
</div>
<div class="item">
<label for="address">Kecamatan<span>*</span></label>
<input id="address" type="text" name="address" required/>
</div>
<div class="item">
<label for="address">Kelurahan/ Desa<span>*</span></label>
<input id="address" type="text" name="address" required/>
</div>
<div class="item">
<label for="phone">No. Telp/ HP<span>*</span></label>
<input id="phone" type="number" name="phone" required/>
</div>
<div class="item">
<label for="zipcode">Kode Pos<span>*</span></label>
<input id="zipcode" type="number" name="zipcode" required/>
</div>
<div class="question">
<label>Agama</label>
<div class="question-answer">
<div>
<input type="radio" value="none" id="radio_1" name="physician"/>
<label for="radio_1" class="radio"><span>Islam</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_3" name="physician"/>
<label for="radio_3" class="radio"><span>Kristen Protestan</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_4" name="physician"/>
<label for="radio_4" class="radio"><span>Kristen Katolik</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_5" name="physician"/>
<label for="radio_5" class="radio"><span>Hindu</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_6" name="physician"/>
<label for="radio_6" class="radio"><span>Buddha</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_6" name="physician"/>
<label for="radio_6" class="radio"><span>Konghucu</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_6" name="physician"/>
<label for="radio_6" class="radio"><span>Lainnya</span></label>
</div>
</div>
</div>
<div class="item">
<label for="education">Pendidikan Terakhir<span>*</span></label>
<input id="education" type="text" name="education" required/>
</div>
<div class="item">
<label for="work">Pekerjaan<span>*</span></label>
<input id="work" type="text" name="work" required/>
</div>
</fieldset>
<br/>
<fieldset>
<legend>Penanggung Jawab Pasien</legend>
<div class="item">
<label for="prelation">Hubungan dengan Pasien<span>*</span></label>
<input id="prelation" type="text" name="prelation" required/>
</div>
<div class="item">
<label for="pname">Nama Penanggung Jawab<span>*</span></label>
<input id="pname" type="text" name="pname" required/>
</div>
<div class="item">
<label for="peducation">Pendidikan Penanggung Jawab<span>*</span></label>
<input id="peducation" type="text" name="peducation" required/>
</div>
<div class="item">
<label for="pwork">Pekerjaan Penanggung Jawab<span>*</span></label>
<input id="pwork" type="text" name="pwork" required/>
</div>
</fieldset>
<div class="btn-block">
<button onclick="submitFunction()">Submit</button>
<script src="index.js"></script>
</div>
<br>
<div class="banner1">
<h3>Rumah Sakit Umum Daerah Arosuka</h3>
<p>Jl. Raya Solok Padang KM. 20 Arosuka Kode Pos 27364</p>
<p>Provinsi Sumatera Barat Telp./ Fax (0755) 31160</p>
<p>Email: raudarosukahatsolo@gmail.com</p>
<br>
</div>
</form>
</div>
</body>
</html>
index.js
function submitFunction() {
alert("Pendaftaran Telah Berhasil");
}
stylesheet.css
html, body {
min-height: 100%;
}
body, div, form, input, select, textarea, label, p {
padding: 0;
margin: 0;
outline: none;
font-family: Roboto, Arial, sans-serif;
font-size: 14px;
color: #666;
line-height: 22px;
}
h1 {
position: absolute;
margin: 0;
font-size: 38px;
color: #fff;
z-index: 2;
line-height: 83px;
}
textarea {
width: calc(100% - 12px);
padding: 5px;
}
.testbox {
display: flex;
justify-content: center;
align-items: center;
height: inherit;
padding: 20px;
}
form {
width: 100%;
padding: 20px;
border-radius: 6px;
background: #fff;
box-shadow: 0 0 8px #669999;
}
.announcement {
position: relative;
color: red;
display: flex;
justify-content: center;
align-items: center;
text-align: center;
}
.banner {
position: relative;
height: 200px;
background-image: url("open-hospital-indonesia-scaled.jpg");
background-size: cover;
display: flex;
justify-content: center;
align-items: center;
text-align: center;
}
.banner1 {
position: relative;
display: grid;
justify-content: center;
align-items: center;
text-align: center;
}
.banner::after {
content: "";
background-color: rgba(0, 0, 0, 0.2);
position: absolute;
width: 100%;
height: 100%;
}
.banner1::after {
content: "";
background-color: rgba(0, 0, 0, 0.2);
position: absolute;
width: 100%;
height: 100%;
}
input, select, textarea {
margin-bottom: 10px;
border: 1px solid #ccc;
border-radius: 3px;
}
input {
width: calc(100% - 10px);
padding: 5px;
}
input[type="date"] {
padding: 4px 5px;
}
textarea {
width: calc(100% - 12px);
padding: 5px;
}
.item:hover p, .item:hover i, .question:hover p, .question label:hover, input:hover::placeholder {
color: #669999;
}
.item input:hover, .item select:hover, .item textarea:hover {
border: 1px solid transparent;
box-shadow: 0 0 3px 0 #669999;
color: #669999;
}
.item {
position: relative;
margin: 10px 0;
}
.item span {
color: red;
}
input[type="date"]::-webkit-inner-spin-button {
display: none;
}
.item i, input[type="date"]::-webkit-calendar-picker-indicator {
position: absolute;
font-size: 20px;
color: #a3c2c2;
}
.item i {
right: 1%;
top: 30px;
z-index: 1;
}
[type="date"]::-webkit-calendar-picker-indicator {
right: 1%;
z-index: 2;
opacity: 0;
cursor: pointer;
}
input[type=radio], input[type=checkbox] {
display: none;
}
label.radio {
position: relative;
display: inline-block;
margin: 5px 20px 15px 0;
cursor: pointer;
}
.column {
display:flex;
justify-content:space-between;
flex-direction:row;
flex-wrap:wrap;
}
.column div {
width:48%;
}
.question span {
margin-left: 30px;
}
.question-answer label {
display: block;
}
label.radio:before {
content: "";
position: absolute;
left: 0;
width: 17px;
height: 17px;
border-radius: 50%;
border: 2px solid #ccc;
}
input[type=radio]:checked + label:before, label.radio:hover:before {
border: 2px solid #669999;
}
label.radio:after {
content: "";
position: absolute;
top: 6px;
left: 5px;
width: 8px;
height: 4px;
border: 3px solid #669999;
border-top: none;
border-right: none;
transform: rotate(-45deg);
opacity: 0;
}
input[type=radio]:checked + label:after {
opacity: 1;
}
.flax {
display:flex;
justify-content:space-around;
}
.btn-block {
margin-top: 10px;
text-align: center;
}
button {
width: 150px;
padding: 10px;
border: none;
border-radius: 5px;
background: #669999;
font-size: 16px;
color: #fff;
cursor: pointer;
}
button:hover {
background: #a3c2c2;
}
@media (min-width: 568px) {
.name-item, .city-item {
display: flex;
flex-wrap: wrap;
justify-content: space-between;
}
.name-item input, .name-item div {
width: calc(50% - 20px);
}
.name-item div input {
width:97%;}
.name-item div label {
display:block;
padding-bottom:5px;
}
}
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