All the user input is being sent to my database, however the radio button and checkbox input is not. Please be specific because I'm new to php and not really sure where to put code suggestions. Thanks!
<form name="form" method="POST" action="final.php">
<h3>Personal Information</h3>
First Name
<input type="text" name="firstname" id="firstname" />
<p>Last Name
<input type="text" name="lastname" id="lastname" />
</p>
<p>Address
<input type="text" name="address" id="address" />
<p>City
<input type="text" name="city" id="city" />
</p>
<p>State
<input type="text" name="state" id="state" />
</p>
<p>Zip Code
<input type="text" name="zipcode" id="zipcode" />
</p>
<p>Birthdate
<input type="text" name="birthdate" id="birthdate" />
</p>
<h3>Contact Information</h3>
<p>Telephone Number
<input type="text" name="telephone" id="telephone" />
</p>
<p>Email
<input type="text" name="email" id="email" />
</p>
<h3>Health Questions</h3>
<p>1. Are you responsible for obtaining and paying for your health insurance?
<br />
<input type="radio" name="group1" id="pay_for_insurance" value="pay_for_insurance">
Yes
<input type="radio" name="group1" id="dont_pay_for_insurance" value="dont_pay_for_insurance">
No<br />
</p>
<p>2. Are you self employed?<br />
<input type="radio" name="group2" id="self_employed" value="self_employed">
Yes
<input type="radio" name="group2" id="not_self_employed" value="not_self_employed">
No<br />
</p>
<p>3. Do you currently have health insurance?
<br />
<input type="radio" name="group3" id="has_health_insurance" value="has_health_insurance">
Yes
<input type="radio" name="group3" id="no_health_insurance" value="no_health_insurance">
No<br />
</p>
<p>4. Are you currently covered by Cobra?
<br />
<input type="radio" name="group4" id="has_cobra" value="has_cobra">
Yes
<input type="radio" name="group4" id="no_cobra" value="no_cobra">
No</p>
<p>5. What is the name of your current insurance company?
<input type="text" name="current_ins" id="current_ins" />
</p>
<p>6. Number of full-time employees
<input type="text" name="employees" id="employees" />
</p>
<p>7. Age of dependants
<br />
•<input type="text" name="dep1" id="dep1" /><br />
•<input type="text" name="dep2" id="dep2" /><br />
•<input type="text" name="dep3" id="dep3" />
</p>
<p>8. Are you a tobacco user?
<br />
<input type="radio" name="group5" id="smoker" value="smoker">
Yes
<input type="radio" name="group5" id="non_smoker" value="non_smoker">
No<br />
</p>
<p>Yes, I am interested in:
<br />
<input type="checkbox" name="insurance[]" id="health" value="health">
Health Insurance
<br />
<input type="checkbox" name="insurance[]" id="life" value="life">
Life Insurance
<br />
<input type="checkbox" name="insurance[]" id="dental" value="dental">
Dental Insurance
<br />
<p>
<input type="submit" name="submit" value="Submit" id="submit" />
</p>
</form>
<?php
$con = mysql_connect ("localhost", "xxx", "xxx") or die ('I cannot connect to the database because: ' . mysql_error());
$db = mysql_select_db ("insurance", $con);
require 'variables.php';
$sql = "INSERT INTO `insurance`.`info` (`firstname`, `lastname`, `address`, `city`, `state`, `zipcode`, `birthdate`, `telephone`, `email`, `pay_for_insurance`, `dont_pay_for_insurance`, `self_employed`, `not_self_employed`, `has_health_insurance`, `no_health_insurance`, `has_cobra`, `no_cobra`, `current_ins`, `employees`, `dep1`, `dep2`, `dep3`, `smoker`, `non_smoker`, `health`, `life`, `dental`)
VALUES ('$firstname', '$lastname', '$address', '$city', '$state', '$zipcode', '$birthdate', '$telephone', '$email', '$pay_for_insurance', '$dont_pay_for_insurance', '$self_employed', '$not_self_employed', '$has_health_insurance', '$no_health_insurance', '$has_cobra', '$no_cobra', '$current_ins', '$employees', '$dep1', '$dep2', '$dep3', '$smoker', '$non_smoker', '$health', '$life', '$dental')";
if (!mysql_query($sql,$con))
{
die('Error: ' . mysql_error());
}
echo "1 record added";
?>
<?php
$ID = mysql_real_escape_string($_POST['ID']);
$firstname = mysql_real_escape_string($_POST['firstname']);
$lastname = mysql_real_escape_string($_POST['lastname']);
$address = mysql_real_escape_string($_POST['address']);
$city = mysql_real_escape_string($_POST['city']);
$state = mysql_real_escape_string($_POST['state']);
$zipcode = mysql_real_escape_string($_POST['zipcode']);
$birthdate = mysql_real_escape_string($_POST['birthdate']);
$telephone = mysql_real_escape_string($_POST['telephone']);
$email = mysql_real_escape_string($_POST['email']);
$pay_for_insurance = mysql_real_escape_string($_POST['pay_for_insurance']);
$dont_pay_for_insurance = mysql_real_escape_string($_POST['dont_pay_for_insurance']);
$self_employed = mysql_real_escape_string($_POST['self_employed']);
$not_self_employed = mysql_real_escape_string($_POST['not_self_employed']);
$has_health_insurance = mysql_real_escape_string($_POST['has_health_insurance']);
$no_health_insurance = mysql_real_escape_string($_POST['no_health_insurance']);
$has_cobra = mysql_real_escape_string($_POST['has_cobra']);
$no_cobra = mysql_real_escape_string($_POST['no_cobra']);
$current_ins = mysql_real_escape_string($_POST['current_ins']);
$employees = mysql_real_escape_string($_POST['employees']);
$dep1 = mysql_real_escape_string($_POST['dep1']);
$dep2 = mysql_real_escape_string($_POST['dep2']);
$dep3 = mysql_real_escape_string($_POST['dep3']);
$smoker = $_POST['group5'] == 'smoker' ? 1 : 0;
$non_smoker = $_POST['group5'] == 'non-smoker' ? 1 : 0;
$smoker = mysql_real_escape_string($_POST['smoker']);
$non_smoker = mysql_real_escape_string($_POST['non_smoker']);
$health = mysql_real_escape_string($_POST['health']);
$life = mysql_real_escape_string($_POST['life']);
$dental = mysql_real_escape_string($_POST['dental']);
?>
