<html>
  <meta charset="utf-8">
  <title>COVID19 Screening Form</title>
<body>

<style>

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.textbutton{
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</style>

<div class="maindiv">

<div class="Imagebanner"><img src="Image/banner.jpg" width=100% height=auto autofocus></div>

<div class="textTopbanner"><label class="labelbanner"><center>COVID19 Screening Form</center></label></div>

<div class="textDiscliption"><label class="textDiscliptionSubLabel">&nbsp;&nbsp;&nbsp;&nbsp;Please fill your name and contact information, You can choose the answer only those that match the history of your risk, Which can choose more than 1 choice.</label></div>  
<br>

<div class="textQ1">
  <label class="textlabelimput1">◉ Please include your name</label><br><br>  
    <input class="textlabelimput2"  type="text" id="n1" placeholder="Name-Surname">
</div>
<br>

<div class="textQ1">
  <label class="textlabelimput1">◉ Please include your telephone</label><br><br> 
    <input class="textlabelimput2" type="tel" id="t1" placeholder="Telephone No.">
</div>
<br>

<div class="textQ1">
  <label class="textlabelimput1">◉ Choose of which is related to you <font color="#BB0000">(Can choose more than 1 choice)</font></label><br><br>

    <input class="chb1" type="checkbox" id="chk1" value="Having body temperature higher than 37.5°C" onclick="quA1()">
    <label class="chb">Having body temperature higher than 37.5°C</label><br>
    <input class="chb1" type="checkbox" id="chk2" value="Dry cough or sneezing" onclick="quA2()">
    <label class="chb">Dry cough or sneezing</label><br>
    <input class="chb1" type="checkbox" id="chk3" value="Loss of taste/loss of appetite" onclick="quA3()">
    <label class="chb">Loss of taste/loss of appetite</label><br>  
    <input class="chb1" type="checkbox" id="chk4" value="Loss of smell" onclick="quA4()">
    <label class="chb">Loss of smell</label><br> 
    <input class="chb1" type="checkbox" id="chk5" value="Have history of contact with Corona Virus patient of suspected person" onclick="quA5()">
    <label class="chb">Have history of contact with Corona Virus patient of suspected person</label><br><br>    
    <input class="chb1" type="checkbox" id="chk6" value="None of the above" onclick="quA6()">
    <label class="chb"><font color="#006600"><b>None of the above</b></font></label> 
   
</div>
<br>

<div class="endtext">
  <label><center><font color="#BB0000">Providing incomplete or misleading information will be liable for any patients/fines under Thailand's the communicable disease Act.</font></center></label>

</div>
<br>
    <center><button class="textbutton" type="button" id="bt1" onclick="SentAws()"><lable class="textButtonSub">Send</lable></button></center>
<br>

</div>
<br>

<p id="text"></p>
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  chk5.checked =false;  

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 function SentAws() {
    if(n1.value == "")
    {
        alert("Please include your full name");
       
    }else if(t1.value == "")
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        alert("Please include your Telephone");
       
    }else if(chkCP == 0)
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        alert("Please select at least 1 Choice");
       
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</body>
</html>
