I have a form which gets patient data and sends it to the database; However an error is occurring when the submit button is click;
Notice: Undefined index: $patient_lastname line 14
Can any one tell me why this error is occuring?
insert.php
<!doctype html>
<html lang="en">
<head>
<title>Form Input Data</title>
<script type="text/javascript" src="http://code.jquery.com/jquery-latest.min.js"></script>
</head>
<body>
<form method="post" action="insert_ac.php">
<br />
<table border="1" bgcolor="lightblue">
<tr>
<th>
Nurse Information
</th>
</tr>
<tr>
<td>
<label style="color: Red">
Please select your name</label>
</td>
</tr>
<tr>
<td>
Fullname
</td>
<td>
<select name="valuelist">
<option value="valuelist" name="nurse_name" value='<?php echo $nurse_name; ?>'></option>
<?php
$value=$_POST ["valuelist"];
$con = mysql_connect("localhost","root","") or die('Could not connect:'.mysql_error());
mysql_select_db("a&e", $con) or die('Could not select database.');
$fetch_nurse_name = mysql_query("SELECT DISTINCT Fullname FROM nurse");
while($throw_nurse_name = mysql_fetch_array($fetch_nurse_name)) {
echo '<option value=\"'.$throw_nurse_name[0].'">'.$throw_nurse_name[0].'</option>';
}
echo "</select>";
?>
</td>
</tr>
<tr>
<td>
<label style="color: Red">
Register Patient</label>
</td>
</tr>
<tr>
<th>
Patient Information
</th>
</tr>
<tr>
<td>
Forename
</td>
<td>
<input type="text" name="patient_name" size="30" required="true" />
</td>
</tr>
<tr>
<td>
Surname
</td>
<td>
<input type="text" name="patient_lastname" size="30" required="true" />
</td>
</tr>
<tr>
<td>
Gender
</td>
<td>
<select name="gender">
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</td>
</tr>
<tr>
<td>
Date_Of_Birth
</td>
<td>
<select name="dateOfBirth">
<option value="">---select date---</option>
<?php for ($i = 1; $i <= 31; $i++) : ?>
<option value="<?php echo ($i < 10) ? '0'.$i : $i; ?>"><?php echo $i; ?></option>
<?php endfor; ?>
</select>
<select name="monthOfBirth">
<option value="">---select month---</option>
<?php for ($i = 1; $i <= 12; $i++) : ?>
<option value="<?php echo ($i < 10) ? '0'.$i : $i; ?>"><?php echo $i; ?></option>
<?php endfor; ?>
</select>
<select name="yearOfBirth">
<option value="">---Select year---</option>
<?php for ($i = 1945; $i < date('Y'); $i++) : ?>
<option value="<?php echo $i; ?>"><?php echo $i; ?></option>
<?php endfor; ?>
</select>
</td>
</tr>
<tr>
<td>
Address
</td>
<td>
<input type="text" name="address" size="54" required="true" />
</td>
</tr>
<tr>
<td>
Patient_History
</td>
<td>
<textarea rows="5" cols="20" name="history" wrap="physical">Enter patient's history</textarea>:<br />
</td>
</tr>
<tr>
<td>
Illness
</td>
<td>
<select name="illness">
<option value="Life Threatening">Critical</option>
<option value="Immediate">Immediate</option>
<option value="Urgent">Urgent</option>
<option value="semi-urgent">Semi-Urgent</option>
<option value="non-urgent">Non-urgent</option>
</select>
</td>
</tr>
<tr>
<td>
Priority
</td>
<td>
<select name="priority">
<option value="high">High Priority</option>
<option value="moderate">Moderate Priority</option>
<option value="low">Low Priority</option>
</select>
</td>
<br />
</tr>
<tr>
<th>
Assessment
</th>
</tr>
<tr>
<td>
Symptoms
</td>
<td>
<input type="text" name="symptoms" size="30" required="true"/>
</td>
</tr>
<tr>
<td>
Diagnosis
</td>
<td>
<input type="text" name="diagnosis" size="30" required="true"/>
</td>
</tr>
<tr>
<td>
Treatment
</td>
<td>
<input type="text" name="treatment" size="30" required="true"/>
</td>
</tr>
<tr>
<td>
<label style="color: Red">
Please assign a doctor</label>
</td>
</tr>
<tr>
<td>
Doctor
</td>
<td>
<select name="valuelist">
<option value="valuelist" name="doc_name" value='<?php echo $doc_name; ?>'></option>
<?php
$value=$_POST ["valuelist"];
$con = mysql_connect("localhost","root","") or die('Could not connect:'.mysql_error());
mysql_select_db("a&e", $con) or die('Could not select database.');
$fetch_doc_name = mysql_query("SELECT DISTINCT Name FROM doctor");
while($throw_doc_name = mysql_fetch_array($fetch_doc_name)) {
echo '<option value=\"'.$throw_doc_name[0].'">'.$throw_doc_name[0].'</option>';
}
echo "</select>";
?>
</td>
</tr>
<tr>
<td align="right">
<input type="submit" name="submit" value="submit" required="true"/>
</td>
</tr>
</table>
</form>
</body>
</html>
insert_ac.php
<?php
$con = mysql_connect("localhost","root","") or die('Could not connect: ' . mysql_error());
mysql_select_db("a&e", $con) or die('Could not select database.');
//get Disease values from form
$symptoms = mysql_real_escape_string($_POST['symptoms']);
$diagnosis = mysql_real_escape_string($_POST['diagnosis']);
$treatment = mysql_real_escape_string($_POST['treatment']);
//Assigning value to variable for Patient
$patient_name = ($_POST['patient_name']);
$patient_lastname = ($_POST['$patient_lastname']);
$gender = ($_POST['$gender']);
$dateOfBirth = ($_POST['$dateOfBirth']);
$monthOfBirth = ($_POST['$monthOfBirth']);
$yearOfBirth = ($_POST['$yearOfBirth']);
$address = ($_POST['address']);
$history = ($_POST['history']);
$illness = ($_POST['illness']);
$priority = ($_POST['priority']);
// Validate date of birth
$date = $dateOfBirth.'-'.$monthOfBirth.'-'.$yearOfBirth;
//Validate
$sql ="INSERT INTO Disease(Illness, Symptoms, Diagnosis, Treatment)
VALUES('$illness', '$symptoms', '$diagnosis', '$treatment')";
mysql_query($sql,$con) or die('Error: ' . mysql_error());
$sql ="INSERT INTO Priority(Priority)
VALUES('$priority')";
mysql_query($sql,$con) or die('Error: ' . mysql_error());
$sql="INSERT INTO Patient(Forename, Surname, Gender, Date_Of_Birth, Address, Patient_History, Illness, Priority, Arrival_Time)
VALUES('$patient_name', '$patient_lastname', '$gender', '$date', '$address', '$history', '$illness', '$priority', NOW())";
mysql_query($sql,$con) or die('Error: ' . mysql_error());
echo "1 record added";
// close connection
mysql_close($con);
?>
