@extends('admin.layouts.app')

@section('title','Add Patient')

@section('header')
Add Patient
@endsection

@section('content')

<form method="POST" action="{{ route('admin.patients.store') }}">
@csrf

<div class="card shadow-sm mb-4">
    <div class="card-header">
        <h5 class="mb-0">Personal Information</h5>
    </div>

    <div class="card-body">

        <div class="row">

            <div class="col-md-4 mb-3">
                <label>First Name</label>
                <input type="text"
                       name="first_name"
                       class="form-control"
                       value="{{ old('first_name') }}"
                       required>
            </div>

            <div class="col-md-4 mb-3">
                <label>Middle Name</label>
                <input type="text"
                       name="middle_name"
                       class="form-control"
                       value="{{ old('middle_name') }}">
            </div>

            <div class="col-md-4 mb-3">
                <label>Last Name</label>
                <input type="text"
                       name="last_name"
                       class="form-control"
                       value="{{ old('last_name') }}"
                       required>
            </div>

            <div class="col-md-3 mb-3">
                <label>Gender</label>

                <select
                    name="gender"
                    class="form-control"
                    required>

                    <option value="">Select</option>

                    <option value="Male"
                        @selected(old('gender')=='Male')>
                        Male
                    </option>

                    <option value="Female"
                        @selected(old('gender')=='Female')>
                        Female
                    </option>

                </select>

            </div>

            <div class="col-md-3 mb-3">
                <label>Date of Birth</label>

                <input
                    type="date"
                    name="date_of_birth"
                    class="form-control"
                    value="{{ old('date_of_birth') }}">
            </div>

            <div class="col-md-3 mb-3">
                <label>National ID</label>

                <input
                    type="text"
                    name="national_id"
                    class="form-control"
                    value="{{ old('national_id') }}">
            </div>

            <div class="col-md-3 mb-3">
                <label>Marital Status</label>

                <select
                    name="marital_status"
                    class="form-control">

                    <option value="">Select</option>

                    <option value="Single">Single</option>

                    <option value="Married">Married</option>

                    <option value="Divorced">Divorced</option>

                    <option value="Widowed">Widowed</option>

                </select>

            </div>

            <div class="col-md-4 mb-3">
                <label>Phone</label>

                <input
                    type="text"
                    name="phone"
                    class="form-control"
                    value="{{ old('phone') }}"
                    required>
            </div>

            <div class="col-md-4 mb-3">
                <label>Email</label>

                <input
                    type="email"
                    name="email"
                    class="form-control"
                    value="{{ old('email') }}">
            </div>

            <div class="col-md-4 mb-3">
                <label>Address</label>

                <input
                    type="text"
                    name="address"
                    class="form-control"
                    value="{{ old('address') }}">
            </div>

        </div>

    </div>
</div>

<div class="card shadow-sm mb-4">

    <div class="card-header">
        <h5 class="mb-0">Medical Information</h5>
    </div>

    <div class="card-body">

        <div class="row">

            <div class="col-md-3 mb-3">

                <label>Blood Group</label>

                <select
                    name="blood_group"
                    class="form-control">

                    <option value="">Select</option>

                    <option>A+</option>
                    <option>A-</option>
                    <option>B+</option>
                    <option>B-</option>
                    <option>AB+</option>
                    <option>AB-</option>
                    <option>O+</option>
                    <option>O-</option>

                </select>

            </div>

            <div class="col-md-3 mb-3">

                <label>Height (cm)</label>

                <input
                    type="number"
                    step="0.01"
                    name="height"
                    class="form-control"
                    value="{{ old('height') }}">

            </div>

            <div class="col-md-3 mb-3">

                <label>Weight (kg)</label>

                <input
                    type="number"
                    step="0.01"
                    name="weight"
                    class="form-control"
                    value="{{ old('weight') }}">

            </div>

            <div class="col-md-6 mb-3">

                <label>Allergies</label>

                <textarea
                    name="allergies"
                    class="form-control"
                    rows="3">{{ old('allergies') }}</textarea>

            </div>

            <div class="col-md-6 mb-3">

                <label>Chronic Diseases</label>

                <textarea
                    name="chronic_diseases"
                    class="form-control"
                    rows="3">{{ old('chronic_diseases') }}</textarea>

            </div>

        </div>

    </div>

</div>

<div class="card shadow-sm mb-4">

    <div class="card-header">
        <h5 class="mb-0">Emergency Contact</h5>
    </div>

    <div class="card-body">

        <div class="row">

            <div class="col-md-4 mb-3">
                <label>Name</label>
                <input type="text"
                       name="emergency_contact_name"
                       class="form-control"
                       value="{{ old('emergency_contact_name') }}">
            </div>

            <div class="col-md-4 mb-3">
                <label>Phone</label>
                <input type="text"
                       name="emergency_contact_phone"
                       class="form-control"
                       value="{{ old('emergency_contact_phone') }}">
            </div>

            <div class="col-md-4 mb-3">
                <label>Relationship</label>
                <input type="text"
                       name="emergency_contact_relation"
                       class="form-control"
                       value="{{ old('emergency_contact_relation') }}">
            </div>

        </div>

    </div>

</div>

<div class="card shadow-sm mb-4">

    <div class="card-header">
        <h5 class="mb-0">Insurance Information</h5>
    </div>

    <div class="card-body">

        <div class="row">

            <div class="col-md-6 mb-3">
                <label>Insurance Company</label>
                <input type="text"
                       name="insurance_company"
                       class="form-control"
                       value="{{ old('insurance_company') }}">
            </div>

            <div class="col-md-6 mb-3">
                <label>Insurance Number</label>
                <input type="text"
                       name="insurance_number"
                       class="form-control"
                       value="{{ old('insurance_number') }}">
            </div>

        </div>

    </div>

</div>

<div class="card shadow-sm mb-4">

    <div class="card-header">
        <h5 class="mb-0">Notes</h5>
    </div>

    <div class="card-body">

        <textarea
            name="notes"
            class="form-control"
            rows="4">{{ old('notes') }}</textarea>

    </div>

</div>

<button class="btn btn-primary">
    Save Patient
</button>

<a href="{{ route('admin.patients.index') }}"
   class="btn btn-secondary">
    Cancel
</a>

</form>

@endsection