formulaires qui ne fonctionnent plus

par pierre du 31 Lun 4 Mar 2013 - 19:53

Bonjours, j'ai 1 formulaire qui ne fonctionne plus depuis 3 jours (rien n'as était touché dessus).

voici le code:

Code:: <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"> <title>fiche bilan</title> <style type="text/css"> form {width:600px;} p {text-align:center;} .red {color:red;} fieldset{margin-bottom:10px;border:0px;} fieldset table {text-align:right;} legend { font-size:1.5em; padding-left:20px; padding-right:20px; margin-bottom:-10px; } .infos {background:#008f72;} .infos legend {background:#00AB89;} .circons {background:#00B9FC;} .circons legend {background:#008EC2;} .vital {background:#D0EB00;} .vital legend {background:#A3B800;} .lesion {background:#fa9e00;} .lesion legend,.lesion p {background:#D18400;} .fonction {background:#FF0000;} .fonction legend,.fonction p {background:#CF0000;} .geste {background: #dd00ff;} .geste legend,.geste p {background:#A800C2;} .geste table {text-align:center;} .identite {background:#B8B8B8;} .identite legend {background:#9E9E9E;} .identite table {text-align:left;} </style> <script type="text/javascript"> function envoiMessage(form) { form.subject.value = "Bilan du SGS n° " + form.number.value + "."; var txt_message = "<div class='bilan'><font color="red">SGS</font> BILAN des pompiers du SGS n° " + form.number.value + "<fieldset class='infos'><legend align='right'>Informations générales</legend><table><tr><td>" + "<strong>Date : </strong><font color="black"><i>" + form.jour.value + "</i></font> / <font color="black"><i>" + form.mois.value + "</i></font> / <font color="black"><i>" + form.an.value + "</i></font></td><td>" + " <strong>Heure : </strong><font color="black"><i>" + form.heur.value + "</i></font><strong> h </strong><font color="black"><i>" + form.min.value + "</i></font></td></tr><tr><td>" + "<strong>Chef d\'agrès : </strong></td><td><font color="black"><i>" + form.ca.value + "</i></font></td></tr><tr><td>" + "<strong>Conducteur : </strong></td><td><i>" + form.cond.value + "</i></td></tr><tr><td>" + "<strong>Equipier 1 : </strong></td><td><i>" + form.e1.value + "</i></td></tr><tr><td> " + "<strong>Equipier 2 : </strong></td><td><i>" + form.e2.value + "</i></td></tr><tr><td> " + '\n' + "<strong>Adresse : </strong></td><td><font color="black"><i>" + '\n' + form.adresse.value + "</i></font></td></tr><tr><td>" + "<strong>Commune : </strong></td><td><font color="black"><i>" + form.commune.value + "</i></font></td></tr></table></fieldset>" + "<fieldset class='circons'><legend align='right'>Bilan Circonstanciel</legend><table><tr><td>" + "<strong>Adresse : </strong></td><td><font color="black"><i>" + form.adrescircon.value + "</i></font></td></tr><tr><td>" + "<strong>Commune : </strong></td><td><font color="black"><i>" + form.communne.value + "</i></font></td></tr><tr><td>" + "<strong>Nombre de victimes : </strong><font color="black"><i>" + form.victimes.value + "</i></font></td><td>" + "<strong>Endroit de l\'accident : </strong><font color="black"><i>" + form.milieu.value + "</i></font></td></tr><tr>" + "<td colspan='2'><strong>Type d\'accident : </strong><font color="black"><i>" + form.typeaccident.value + "</i></font></td></tr><tr><td>" + "<strong>AVP : </strong><font color="black"><i>" + form.avpleft.value + "</i></font></td><td>" + "<strong> contre : </strong><font color="black"><i>" + form.avpright.value + "</i></font></td></tr><tr><td>" + "<strong>Le blessé : </strong><font color="black"><i>" + form.bless.value + "</i></font></td><td>" + "<strong>Automobiliste : </strong><font color="black"><i>" + form.automobile.value + "</i></font></td></tr></table></fieldset>" + "<fieldset class='vital'><legend align='right'>Bilan Vital</legend><table><tr><td>" + "<strong>Hémorragie ? </strong><font color="black"><i>" + form.hemo.value + "</i></font></td><td colspan='2'>" + "<strong>Obstruction des voies aériennes ? </strong><font color="black"><i>" + form.broncho.value + "</i></font></td></tr></table></fieldset>" + "<fieldset class='lesion'><legend align='right'>Bilan Lésionnel</legend><p>Malaise</p><table><tr><td>" + "<strong>Depuis combien de temps ? : </strong><font color="black"><i>" + form.malaisetime.value + "</i></font></td></tr><tr><td>" + "<strong>C\'est la première fois ? : </strong><font color="black"><i>" + form.malaisefirst.value + "</i></font></td></tr><tr><td>" + "<strong>Avez-vous un traitement ? : </strong><font color="black"><i>" + form.malaisetraite.value + "</i></font></td></tr><tr><td>" + "<strong>Avez-vous été hospitalisé ? : </strong><font color="black"><i>" + form.malaisehospi.value + "</i></font></td></tr></table>" + "<p>Traumatisme</p><table><tr><td>" + "<strong>Suspicion fracture ? </strong><font color="black"><i>" + form.fractur.value + "</i></font></td><td>" + "<strong>Plaie ? </strong><font color="black"><i>" + form.plaie.value + "</i></font></td><td>" + "<strong>Brûlure ? </strong><font color="black"><i>" + form.brule.value + "</i></font><td></tr><tr><td>" + "<strong>Douleurs abdominales ? </strong><font color="black"><i>" + form.abdodoloris.value + "</i></font></td><td>" + "<strong>Paralysie ? </strong><font color="black"><i>" + form.paralys.value + "</i></font></td><td>" + "<strong>Douleurs thoraciques ? </strong><font color="black"><i>" + form.toraxdolor.value + "</i></font></td></tr><tr><td colspan='2'>" + "<strong>Vomissements ? </strong><font color="black"><i>" + form.vomito.value + "</i></font></td><td>" + "<strong>Convulsions ? </strong><font color="black"><i>" + form.convuls.value + "</i></font></td></tr></table></fieldset>" + "<fieldset class='fonction'><legend align='right'>Bilan fonctionnel</legend><p>Conscience</p><table><tr><td>" + "<strong>Etat de la victime : </strong></td><td><font color="black"><i> " + form.victimestat.value + "</i></font></td><td>" + "<strong>PCI ? </strong><font color="black"><i>" + form.pci.value + "</i></font></td></tr><tr><td>" + "<strong>Durée : </strong></td><td colspan='2'> <font color="black"><i>" + form.dureeperte.value + "</i></font></td></tr><tr><td>" + "<strong>Désorienté ? </strong><font color="black"><i>" + form.desorient.value + "</i></font></td><td>Agité ? <font color="black"><i>" + form.agite.value + "</i></font></td><td>" + "<strong>Obnubilé ? </strong><font color="black"><i>" + form.obnubil.value + "</i></font></td></tr><tr><td>" + "<strong>Pupilles : </strong></td><td><font color="black"><i>" + form.pupil.value + "</i></font></td></tr><tr><td>" + "<strong>Motricité des bras ? </strong><font color="black"><i>" + form.armmotor.value + "</i></font></td><td> </td><td>" + "<strong>Motricité des pieds ? </strong><font color="black"><i>" + form.feetmotor.value + "</i></font></td></tr><tr><td>" + "<strong>Sensibilité des bras ? </strong><font color="black"><i>" + form.armsens.value + "</i></font></td><td> </td><td>" + "<strong>Sensibilité des pieds ? </strong><font color="black"><i>" + form.feetsens.value + "</i></font></td></tr></table>" + "<p>Ventilation</p><table><tr><td colspan='2'>" + "<strong>Fréquence : </strong><font color="black"><i>" + form.ventiFQ.value + "</i></font></td></tr><tr><td>" + "<strong>Amplitude ? </strong><font color="black"><i>" + form.ventilampli.value + "</i></font></td><td>" + "<strong>Régularité ? </strong><font color="black"><i>" + form.ventilregul.value + "</i></font></td></tr><tr><td colspan='2'>" + "<strong>Douleurs ? Gênes ? </strong><font color="black"><i>" + form.ventildolor.value + "</i></font></td></tr><tr><td>" + "<strong>Bruyantes ? </strong><font color="black"><i>" + form.ventilbruit.value + "</i></font></td><td>" + "<strong>Pauses ? </strong><font color="black"><i>" + form.ventilpause.value + "</i></font></td></tr><tr><td>" + "<strong>Cyanose ? </strong><font color="black"><i>" + form.cyanos.value + "</i></font></td><td>" + "<strong>Sueurs ? </strong><font color="black"><i>" + form.sueur.value + "</i></font></td></tr></table>" + "<p>Circulation </p><table><tr><td colspan='2'>" + "<strong>Fréquence : </strong><font color="black"><i>" + form.circuFQ.value + "</i></font></td></tr><tr><td>" + "<strong>Amplitude ? </strong><font color="black"><i>" + form.circulampli.value + "</i></font></td><td>" + "<strong>Régularité ? </strong><font color="black"><i>" + form.circulregul.value + "</i></font></td></tr><tr><td>" + "<strong>Poul radial ? </strong><font color="black"><i>" + form.pouls.value + "</i></font></td><td>" + "<strong>Angoisse ? </strong><font color="black"><i>" + form.angois.value + "</i></font></td></tr><tr><td>" + "<strong>Soif ? </strong><font color="black"><i>" + form.soif.value + "</i></font></td><td>" + "<strong>Paleurs ? </strong><font color="black"><i>" + form.pale.value + "</i></font></td></tr><tr><td>" + "<strong>Marbrures ? </strong><font color="black"><i>" + form.marbre.value + "</i></font></td><td>" + "<strong>Douleur, échelle de 1 à 10 : </strong><font color="black"><i>" + form.doloris.value + "</i></font></td></tr></table></fieldset>" + "<fieldset class='geste'><legend align='right'>Gestes effectués</legend><table><tr><td>"; if(form.choix[0].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " PLS - "; if(form.choix[1].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " RCP - "; if(form.choix[2].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Attelle / Echarpe - "; if(form.choix[3].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Collier cervical</td></tr><tr><td>" + "O² en inhalation : " + form.O2.value + "</td></tr><tr><td>"; if(form.choix[4].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Insufflation O² - "; if(form.choix[5].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Couverture isotherme - "; if(form.choix[6].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Point de compression </td></tr><tr><td>"; if(form.choix[7].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Heimlich - "; if(form.choix[8].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Matelas coquille - "; if(form.choix[9].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Pansement - "; if(form.choix[10].checked) {txt_message += "<font color="red"><strong> X </strong></font>";} else {txt_message += "<font color="green"> O </font>";} txt_message += " Emballage</td></tr></table></fieldset>" + "<fieldset class='identite'><legend align='right'>Identité</legend><table><tr><td>" + "<strong>Nom : </strong></td><td> <font color="black"><i>" + form.nom.value + "</i></font></td></tr><tr><td>" + "<strong>Prénom : </strong></td><td> <font color="black"><i>" + form.prenom.value + "</i></font></td></tr><tr><td>" + "<strong>Date de naissance : </strong></td><td> <font color="black"><i>" + form.anniv.value + "</i></font></td></tr><tr><td>" + "<strong>Adresse : </strong></td><td> <font color="black"><i>" + form.adressident.value + "</i></font></td></tr><tr><td>" + "<strong>Sexe : </strong></td><td> <font color="black"><i>" + form.sexe.value + "</i></font></td></tr><tr><td>" + "<strong>Chef d\'agrès : </strong></td><td> <font color="black"><i>" + form.chef.value + "</i></font></td></tr><tr><td>" + "<strong>Véhicule : </strong></td><td> <font color="black"><i>" + form.vehicule.value + "</i></font></td></tr></table></fieldset></div>" + '\n'; form.message.value = txt_message; } </script> </head> <body> <form action="http://sgs-virtuel.forumactif.org/post" method="post" name="post" enctype="multipart/form-data" onSubmit="envoiMessage(this)" > <input type="hidden" name="lt" value="0" /> <input type="hidden" name="mode" value="newtopic" /> <input type="hidden" name="topictype" value="0" checked="checked" /> <input type="hidden" name="message" value="" /> <input type="hidden" name="f" value="1" /> <input type="hidden" name="subject" id="titre" value="" /> <p><span class="red">SDIS 31</span> BILAN des Pompier du SGS n° <input type="text" name="number" id="number" size="2" maxlength="3"/></p> <fieldset class="infos"><legend align="right">Informations générales</legend> <table><tr> <td>Date : <input type="text" name="jour" id="jour" size="2" maxlength="2"/> / <input type="text" name="mois" id="mois" size="2" maxlength="2"/> / <input type="text" name="an" id="an" size="2" maxlength="2"/></td> <td>Heure : <input type="text" name="heur" id="heur" size="2" maxlength="2" /> h <input type="text" name="min" id="min" size="2" maxlength="2" /></td> </tr><tr> <td>Chef d'agrès : </td><td><input type="text" name="ca" id="ca" size="40" maxlength="30" /></td> </tr><tr> <td>Conducteur : </td><td><input type="text" name="cond" id="cond" size="40" maxlength="30"/></td> </tr><tr> <td>Equipier 1 : </td><td><input type="text" name="e1" id="e1" size="40" maxlength="30"/></td> </tr><tr> <td>Equipier 2 : </td><td><input type="text" name="e2" id="e2" size="40" maxlength="30"/></td> </tr><tr> <td>Adresse : </td><td><input type="text" name="adresse" id="adresse" size="40" maxlength="40"/></td> </tr><tr> <td>Commune : </td><td><input type="text" name="commune" id="commune" size="40" maxlength="40"/></td> </tr></table></fieldset> <fieldset class="circons"><legend align="right">Bilan Circonstanciel</legend> <table><tr> <td>Adresse : </td><td><input type="text" name="adrescircon" id="adrescircon" size="40" maxlength="30"/></td> </tr><tr> <td>Commune : </td><td><input type="text" name="communne" id="communne" size="40" maxlength="30"/></td> </tr><tr> <td>Nombre de victimes : <input type="text" name="victimes" id="victimes" size="2" maxlength="2"/> </td> <td>Milieu de l'accident : <select name="milieu" id="milieu"> <option value="Agricole" selected="selected">Agricole</option> <option value="Scolaire">Scolaire</option> <option value="Sportif">Sportif</option> <option value="Domestique">Domestique</option> <option value="Voie Publique">Voie Publique</option> <option value="Travail">Travail</option> </select></td> </tr><tr> <td colspan="2">Type d'accident : <select name="typeaccident" id="typeaccident"> <option value="Accouchement" selected="selected">Accouchement</option> <option value="Agitation Psy">Agitation Psy</option> <option value="Agression">Agression</option> <option value="Arme blanche">Arme blanche</option> <option value="Arme à feu">Arme à feu</option> <option value="Bagarre">Bagarre</option> <option value="Malaise">Malaise</option> <option value="Noyade">Noyade</option> <option value="Pendaison">Pendaison</option> <option value="Electrisation">Electrisation</option> <option value="Ethylisme">Ethylisme</option> <option value="Corps étranger">Corps étranger</option> <option value="Intoxication médicamenteuse">Intoxication médicamenteuse</option> <option value="Chute de sa hauteur">Chute de sa hauteur</option> <option value="Chute avec notion de hauteur">Chute avec notion de hauteur</option> <option value="Inhalation fumées">Inhalation fumées</option> </select></td> </tr><tr> <td>AVP : <input type="text" name="avpleft" id="avpleft" size="30" maxlength="30"/></td><td> contre : <input type="text" name="avpright" id="avpright" size="30" maxlength="30"/></td> </tr><tr> <td>Le blessé : <select name="bless" id="bless"> <option value="piéton" selected="selected">piéton</option> <option value="cycliste">cycliste</option> <option value="motocycliste">motocycliste</option> <option value="conducteur véhicule 1">conducteur véhicule 1</option> <option value="Passager voiture 1">Passager voiture 1</option> <option value="conducteur voiture 2">conducteur voiture 2</option> <option value="passager voiture 2">passager voiture 2</option> <option value="conducteur poids lourd">conducteur poids lourd</option> </select></td> <td>Automobiliste : <select name="automobile" id="automobile"> <option value="incarcéré" selected="selected">incarcéré</option> <option value="éjecté">éjecté</option> <option value="indemne">indemne</option> <option value="blessé léger">blessé léger</option> <option value="blessé grave">blessé grave</option> </select></td> </tr></table></fieldset> <fieldset class="vital"><legend align="right">Bilan Vital</legend> <table><tr> <td>Hémorragie ? <select name="hemo" id="hemo" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td colspan="2">Obstruction des voies aériennes ? <select name="broncho" id="broncho" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Conscience ? <select name="consciens" id="consciens" > <option value="oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td>Ventilation ? <select name="ventil" id="ventil" > <option value="oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td>Circulation ? <select name="circulat" id="circulat" > <option value="oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> </tr></table></fieldset> <fieldset class="lesion"><legend align="right">Bilan Lésionnel</legend> <p>Malaise</p> <table><tr> <td>Depuis combien de temps ? : </td><td><input type="text" name="malaisetime" id="malaisetime" size="40" maxlength="30"/></td> </tr><tr> <td>C'est la première fois ? : </td><td><input type="text" name="malaisefirst" id="malaisefirst" size="40" maxlength="30"/></td> </tr><tr> <td>Avez-vous un traitement ? : </td><td><input type="text" name="malaisetraite" id="malaisetraite" size="40" maxlength="30"/></td> </tr><tr> <td>Avez-vous été hospitalisé ? : </td><td><input type="text" name="malaisehospi" id="malaisehospi" size="40" maxlength="30"/></td> </tr></table> <p>Traumatisme</p> <table><tr> <td>Suspicion fracture ? <select name="fractur" id="fractur" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Plaie ? <select name="plaie" id="plaie" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Brûlure ? <select name="brule" id="brule" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Douleurs abdominales ? <select name="abdodoloris" id="abdodoloris" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Paralysie ? <select name="paralys" id="paralys" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Douleurs thoraciques ? <select name="toraxdolor" id="toraxdolor" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td colspan="2">Vomissements ? <select name="vomito" id="vomito" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Convulsions ? <select name="convuls" id="convuls" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr></table></fieldset> <fieldset class="fonction"><legend align="right">Bilan fonctionnel</legend> <p>Conscience</p> <table><tr> <td>Etat de la victime : </td> <td><select name="victimestat" id="victimestat" > <option value="Consciente" selected="selected">Consciente</option> <option value="<font color="red"><strong>Inconsciente</strong></font>">Inconsciente</option> </select></td> <td>PCI ? <select name="pci" id="pci" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Durée : </td><td colspan="2"><input type="text" name="dureeperte" id="dureeperte" size="40" maxlength="30"/></td> </tr><tr> <td>Désorienté ? <select name="desorient" id="desorient" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Agité ? <select name="agite" id="agite" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Obnubilé ? <select name="obnubil" id="obnubil" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Pupilles : </td><td> <select name="pupil" id="pupil" > <option value="Réactives" selected="selected">Réactives</option> <option value="<font color="red"><strong>Aréactives</strong></font>">Aréactives</option> </select></td> </tr><tr> <td>Motricité des bras ? <select name="armmotor" id="armmotor" > <option value="Oui" selected="selected">Oui</option> <option value="Non">Non</option> </select></td> <td> </td> <td>Motricité des pieds ? <select name="feetmotor" id="feetmotor" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> </tr><tr> <td>Sensibilité des bras ? <select name="armsens" id="armsens" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td> </td> <td>Sensibilité des pieds ? <select name="feetsens" id="feetsens" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> </tr></table> <p>Ventilation</p> <table><tr> <td colspan="2">Fréquence : <input type="text" name="ventiFQ" id="ventiFQ" size="40" maxlength="30"/></td> </tr><tr> <td>Amplitude ? <select name="ventilampli" id="ventilampli" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td>Régularité ? <select name="ventilregul" id="ventilregul" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> </tr><tr> <td colspan="2">Douleurs ? Gênes ? <select name="ventildolor" id="ventildolor" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Bruyantes ? <select name="ventilbruit" id="ventilbruit" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Pauses ? <select name="ventilpause" id="ventilpause" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Cyanose ? <select name="cyanos" id="cyanos" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Sueurs ? <select name="sueur" id="sueur" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr></table> <p>Circulation </p> <table><tr> <td colspan="2">Fréquence : <input type="text" name="circuFQ" id="circuFQ" size="40" maxlength="30"/></td> </tr><tr> <td>Amplitude ? <select name="circulampli" id="circulampli" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td>Régularité ? <select name="circulregul" id="circulregul" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> </tr><tr> <td>Poul radial ? <select name="pouls" id="pouls" > <option value="Oui" selected="selected">Oui</option> <option value="<font color="red"><strong>Non</strong></font>">Non</option> </select></td> <td>Angoisse ? <select name="angois" id="angois" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Soif ? <select name="soif" id="soif" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Paleurs ? <select name="pale" id="pale" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> </tr><tr> <td>Marbrures ? <select name="marbre" id="marbre" > <option value="<font color="red"><strong>Oui</strong></font>">Oui</option> <option value="Non" selected="selected">Non</option> </select></td> <td>Douleur, échelle de 1 à 10 : <input type="text" name="doloris" id="doloris" size="2" maxlength="2"/></td> </tr></table></fieldset> <fieldset class="geste"><legend align="right">Gestes effectués</legend> <table><tr> <td><input type="checkbox" name="choix" value="PLS">PLS <input type="checkbox" name="choix" value="RCP">RCP <input type="checkbox" name="choix" value="Attel">Attelle / Echarpe <input type="checkbox" name="choix" value="cervical">Collier cervical</td> </tr><tr> <td>O² en inhalation : <input type="text" name="O2" id="O2" size="40" maxlength="30"/></td> </tr><tr> <td><input type="checkbox" name="choix" value="Insuf">Insufflation O² <input type="checkbox" name="choix" value="isotherme">Couverture isotherme <input type="checkbox" name="choix" value="compression">Point de compression </td> </tr><tr> <td><input type="checkbox" name="choix" value="Heimlich">Heimlich <input type="checkbox" name="choix" value="coquil">Matelas coquille <input type="checkbox" name="choix" value="Pansement">Pansement <input type="checkbox" name="choix" value="Emballage">Emballage</td> </tr></table></fieldset> <fieldset class="identite"><legend align="right">Identité</legend> <table><tr> <td>Nom : </td><td><input type="text" name="nom" id="nom" size="40" maxlength="30"/></td> </tr><tr> <td>Prénom : </td><td><input type="text" name="prenom" id="prenom" size="40" maxlength="30"/></td> </tr><tr> <td>Date de naissance : </td><td><input type="text" name="anniv" id="anniv" size="10" maxlength="10" value="j j /mm/aaaa"/></td> </tr><tr> <td>Adresse : </td><td><input type="text" name="adressident" id="adressident" size="40" maxlength="30"/></td> </tr><tr> <td>Sexe : </td> <td><select name="sexe" id="sexe" > <option value="Masculin" selected="selected">Masculin</option> <option value="Féminin">Féminin</option></select></td> </tr><tr> <td>Chef d'agrès : </td><td><input type="text" name="chef" id="chef" size="40" maxlength="30"/></td> </tr><tr> <td>Véhicule : </td><td><input type="text" name="vehicule" id="vehicule" size="40" maxlength="30"/></td> </tr></table></fieldset><br> <input type="submit" name="post" value="Envoyer"><input type="reset" /> </form> </body></html>