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index.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Raport Specialistik</title>
<link href="https://fonts.googleapis.com/css2?family=Roboto:wght@400;500&display=swap" rel="stylesheet">
<link rel="stylesheet" href="style.css">
</head>
<body>
<div class="container">
<!-- Header Section -->
<div class="header">
<div class="logo"></div>
<div class="header-info">
<p>ORDINANCA SPECIALISTIKE PEDIATRIKE</p>
<h1>"R.H. PEDIATRIA"</h1>
<p class="doctor-name">Dr. med. Rexhep Hoxha</p>
<p>Specialist - Pediatër</p>
</div>
<div class="contact-info">
<p>Tel: 044 117 605</p>
<p>Rr.Shahin Kolonja nr.10</p>
</div>
</div>
<!-- Title -->
<div class="title">RAPORT SPECIALISTIK</div>
<!-- Patient Information Section -->
<div class="patient-info">
<div class="input-group">
<label for="patient-first-name">Emri:</label>
<input type="text" id="patient-first-name" name="patient-first-name">
</div>
<div class="input-group">
<label for="patient-last-name">Mbiemri:</label>
<input type="text" id="patient-last-name" name="patient-last-name">
</div>
<div class="input-group">
<label for="birthday">Datëlindja:</label>
<input type="date" id="birthday" name="birthday">
</div>
<div class="input-group">
<label for="location">Vendi:</label>
<input type="text" id="location" name="location">
</div>
</div>
<!-- Diagnose Section -->
<div class="diagnose-section">
<label for="diagnose">Dg.</label>
<textarea id="diagnose" name="diagnose"></textarea>
</div>
<!-- Therapy Section -->
<div class="therapy-section">
<label for="therapy">Th.</label>
<textarea id="therapy" name="therapy"></textarea>
</div>
<!-- Medical Information Section -->
<div class="medical-info">
<div class="info-item">
<label for="te">TE.</label>
<input type="text" id="te" name="te">
</div>
<div class="info-item">
<label for="pl">PL.</label>
<input type="text" id="pl" name="pl">
</div>
<div class="info-item">
<label for="gjl">GJL.</label>
<input type="text" id="gjl" name="gjl">
</div>
<div class="info-item">
<label for="pt">PT.</label>
<input type="text" id="pt" name="pt">
</div>
<div class="info-item">
<label for="gjt">GJT.</label>
<input type="text" id="gjt" name="gjt">
</div>
<div class="info-item">
<label for="pk">PK.</label>
<input type="text" id="pk" name="pk">
</div>
<div class="info-item">
<label for="par">PAR.</label>
<input type="text" id="par" name="par">
</div>
<div class="info-item">
<label for="fr">FR.</label>
<input type="text" id="fr" name="fr">
</div>
<div class="info-item">
<label for="fz">FZ.</label>
<input type="text" id="fz" name="fz">
</div>
<div class="info-item">
<label for="vaks">VAKS.</label>
<input type="text" id="vaks" name="vaks">
</div>
</div>
<!-- Footer Section -->
<div class="footer">
<div class="footer-left">
<div class="date-location">
<div class="date">
<label for="date-select">Data:</label>
<input type="date" id="date-select" name="date">
</div>
<div class="location">
<p>Prizren</p>
</div>
</div>
</div>
<div class="footer-right">
<div class="signature-line"></div>
<p class="signature-text">Nënshk. e faks.</p>
</div>
</div>
<div class="footer-extra-text">
<p>NË KONTROLLË ÇDO HERË ME KËTË RAPORT MBRENDA 3 DITE</p>
</div>
</div>
<script src="script.js"></script>
</body>
</html>