50 lines
1.3 KiB
PHP
50 lines
1.3 KiB
PHP
@extends('layouts.user')
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@section('title', 'Data Diri')
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@section('content')
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<div class="container">
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<h4 class="mb-4">Isi Data Diri Anda Sebelum Diagnosa</h4>
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<form action="{{ route('user.data_diri.store') }}" method="POST">
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@csrf
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<div class="mb-3">
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<label>Nama Lengkap</label>
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<input type="text" name="nama" class="form-control" required>
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</div>
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<div class="mb-3">
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<label>Jenis Kelamin</label>
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<select name="jenis_kelamin" class="form-control">
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<option>Laki-laki</option>
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<option>Perempuan</option>
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</select>
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</div>
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<div class="mb-3">
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<label>Tempat Lahir</label>
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<input type="text" name="tempat_lahir" class="form-control">
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</div>
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<div class="mb-3">
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<label>Tanggal Lahir</label>
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<input type="date" name="tanggal_lahir" class="form-control">
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</div>
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<div class="mb-3">
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<label>Alamat</label>
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<textarea name="alamat" class="form-control"></textarea>
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</div>
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<div class="mb-3">
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<label>No Telp</label>
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<input type="text" name="no_telp" class="form-control">
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</div>
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<button class="btn btn-primary">Simpan & Lanjut Diagnosa</button>
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</form>
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</div>
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@endsection |