Health Screening Questionnaire

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-xl mx-auto rounded-[32px] border-2 border-[#231b17] bg-[#fffdf9] px-6 py-7 shadow-none sm:px-8"
>
  <h2 class="text-2xl font-semibold tracking-tight text-[#231b17] mb-6">Health Screening Questionnaire</h2>

  <div class="space-y-4">
    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Full Name</label>
      <input type="text" name="fullName" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" placeholder="John Doe" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Primary Symptoms</label>
      <select name="symptoms" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" 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="mb-1.5 block text-sm font-medium text-[#4f4138]">Recent Travel (14 days)?</label>
      <div class="mt-2 flex flex-wrap gap-2">
        <label class="inline-flex items-center gap-2 rounded-full border border-[#d9cdc3] bg-white px-3 py-2 text-sm text-[#4f4138]"><input type="radio" name="recentTravel" value="Yes" class="accent-[#E14E3A]" required /> Yes</label>
        <label class="inline-flex items-center gap-2 rounded-full border border-[#d9cdc3] bg-white px-3 py-2 text-sm text-[#4f4138]"><input type="radio" name="recentTravel" value="No" class="accent-[#E14E3A]" required /> No</label>
      </div>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Additional Symptoms</label>
      <textarea name="additionalSymptoms" rows="4" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8 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="mt-6 w-full rounded-[18px] bg-[#231b17] py-3 text-sm font-semibold text-white transition hover:bg-[#3a2f29]">
    Submit
  </button>
</form>