Health Screening Questionnaire

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-lg mx-auto bg-white rounded-2xl shadow-sm border border-gray-200 p-8"
>
  <h2 class="text-xl font-bold text-gray-900 mb-6">Health Screening Questionnaire</h2>

  <div class="space-y-4">
    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Full Name</label>
      <input type="text" name="fullName" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="John Doe" required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Primary Symptoms</label>
      <select name="symptoms" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" required>
        <option value="">Select...</option>
        <option value="None">None</option>
        <option value="Fever">Fever</option>
        <option value="Cough">Cough</option>
        <option value="Fatigue">Fatigue</option>
        <option value="Shortness of breath">Shortness of breath</option>
        <option value="Other">Other</option>
      </select>
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Recent Travel (14 days)?</label>
      <div class="flex gap-6 mt-1">
        <label class="inline-flex items-center gap-2 text-sm text-gray-700"><input type="radio" name="recentTravel" value="Yes" class="accent-[#E14E3A]" required /> Yes</label>
        <label class="inline-flex items-center gap-2 text-sm text-gray-700"><input type="radio" name="recentTravel" value="No" class="accent-[#E14E3A]" required /> No</label>
      </div>
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Additional Symptoms</label>
      <textarea name="additionalSymptoms" rows="4" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A] resize-none" placeholder="Describe any other symptoms..." required></textarea>
    </div>
  </div>

  <!-- Honeypot (spam protection) -->
  <div style="display:none">
    <input type="text" name="_gotcha" style="display:none" />
  </div>

  <button type="submit" class="w-full bg-[#E14E3A] text-white py-3 rounded-lg font-semibold hover:bg-[#c9432f] transition mt-6">
    Submit
  </button>
</form>