@include('forms/elements/header_start')

<link href="{{ asset('assets/plugins/select2/css/select2.min.css') }}" rel="stylesheet" type="text/css" />
<link href="{{ asset('assets/plugins/bootstrap-datepicker/css/bootstrap-datepicker.min.css') }}" rel="stylesheet">
<link href="{{ asset('assets/plugins/dropzone/dist/dropzone.css') }}" rel="stylesheet" type="text/css">

<style>
    .card-header {
        background-color: #027eaa!important;
    }
    label{
        font-size: 22px;
    }
</style>
@include('patients/elements/header_end')

<!-- Page title -->
<ul class="list-inline menu-left mb-0">
    <li class="list-inline-item">
        <button type="button" class="button-menu-mobile open-left waves-effect">
            <i class="ion-navicon"></i>
        </button>
    </li>
    <li class="hide-phone list-inline-item app-search">
        <h2 class="page-title">Cardiac</h2>
    </li>
</ul>

<div class="clearfix"></div>
</nav>

</div>
<!-- Top Bar End -->

<!-- ==================
     PAGE CONTENT START
     ================== -->
<style>
    body {
        background-color: transparent!important;
        background-image: url({{ url('/assets/images/background/Cardiac.jpeg') }});
        max-width: 100%;
        background-size: auto;
        background-repeat: no-repeat;
        background-attachment: fixed;
        background-position: center;
        /*background-color: #cccccc!important;*/
    }
</style>
<div class="page-content-wrapper">


    <div class="container-fluid col-md-10 offset-md-1">


        <div class="pull-right">
            <div class=" text-center">
                <button type="button" class="btn btn-primary waves-effect waves-light btn-lg help-modal-form" data-toggle="modal" data-target="#myModal"><i class="fa fa-info-circle"></i></button>
            </div>

            <!-- sample modal content -->
            <div id="myModal" class="modal fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">
                <div class="modal-dialog">
                    <div class="modal-content">
                        <div class="modal-header">
                            <h5 class="modal-title mt-0" id="myModalLabel">Instructions</h5>
                            <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
                        </div>
                        <div class="modal-body">
                            <h4 class="card-header">Filling the form</h4>
                            <p style="padding:10px;">Please fill in the form, including any information relating to the questions</p>
                            <p style="padding:10px;">On certain questions, you may be greeted with further fields to
                                include a date or other things.</p>
                            <hr>
                            <h4 class="card-header">Contact Us</h4>
                            <p style="padding:10px;">
                                If you have any issues filling in the form, please
                                <a href="{{ route('support.support.patient') }}">contact us</a>
                                and we will assist with any issues you may have using the system.
                            </p>
                        </div>
{{--                        <div class="modal-footer">--}}
{{--                            <button type="button" class="btn btn-secondary waves-effect" data-dismiss="modal">Close</button>--}}
{{--                            <button type="button" class="btn btn-primary waves-effect waves-light">Save changes</button>--}}
{{--                        </div>--}}
                    </div><!-- /.modal-content -->
                </div><!-- /.modal-dialog -->
            </div><!-- /.modal -->
        </div>


        <div class="row">
            <div class="col-md-12 col-xl-12">
                <div class="card m-b-30">
                    <div class="card-header text-center">25% complete</div>

                    <div class="card-body">

{{--                        <h4 class="mt-0 header-title">Animated stripes</h4>--}}
                        <div class="">
                            <div class="progress">
                                <div class="progress-bar progress-bar-striped progress-bar-animated" role="progressbar" aria-valuenow="25" aria-valuemin="0" aria-valuemax="100" style="width: 25%"></div>
                            </div>
                        </div>
                    </div>
                </div>
             </div>

        </div>
        <!-- end row -->

        <div class="row">
            <div class="col-md-9 col-xl-9">
                <div class="card m-b-30">
                    <h4 class="card-header mt-0">Cardiac</h4>

                    <div class="card-body">

                        <form action="{{ isset($id) ? route('patients.store.cardiac.answer', ['id' => $id]) : route('patients.store.cardiac.answer') }} " method="POST" enctype="multipart/form-data" autocomplete="off">
                            @csrf

                            <div class="row">
                                <div class="col-12">

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align:center;">Do you have high blood pressure or take blood pressure medications?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control bp-select" id="question-bp" name="blood_pressure_medication" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('blood_pressure_medication')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('blood_pressure_medication')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select from the dropdown.</p>--}}

                                            @if ($errors->has('blood_pressure_medication'))
                                                <span class="badge badge-danger">{{ $errors->first('blood_pressure_medication') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align:center;">What is your daily blood pressure – bottom and top number range</label>
                                        <div class="row">
                                            <div class="col-sm-3 offset-sm-3">
                                                <input type="number" min="0" max="200" class="form-control" placeholder="Enter lower bp" id="lower-bp" name="bottom_blood_pressure" value="{{ old('bottom_blood_pressure') }}">

{{--                                                <p>Please enter your lower blood pressure value.</p>--}}

                                                @if ($errors->has('bottom_blood_pressure'))
                                                    <span class="badge badge-danger">{{ $errors->first('bottom_blood_pressure') }}</span>
                                                @endif

                                            </div>
                                            <div class="col-sm-3">
                                                <input type="number" min="0" max="200" class="form-control" placeholder="Enter higher bp" id="higher-bp" name="top_blood_pressure" value="{{ old('top_blood_pressure') }}">

{{--                                                <p>Please enter your upper blood pressure value.</p>--}}

                                                @if ($errors->has('top_blood_pressure'))
                                                    <span class="badge badge-danger">{{ $errors->first('top_blood_pressure') }}</span>
                                                @endif

                                            </div>
                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align:center;">Have you had heart surgery?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control heart-surgery-select" id="heart-surgery" name="had_heart_surgery" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('had_heart_surgery')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('had_heart_surgery')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select from the dropdown.</p>--}}

                                            @if ($errors->has('had_heart_surgery'))
                                                <span class="badge badge-danger">{{ $errors->first('had_heart_surgery') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                </div>
                            </div>

{{--                            SURGERY DETAILS    --}}

                            <div class="form-group row surgery-details" style="{{ old("had_heart_surgery") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Surgery Name
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Plese enter the name of the surgery"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <input type="text" class="form-control" placeholder="Enter surgery name" id="heart-surgery-name" name="heart_surgery_name" value="{{ old('heart_surgery_name') }}">

{{--                                    <p>Please enter the name of the surgery conducted.</p>--}}

                                    @if ($errors->has('heart_surgery_name'))
                                        <span class="badge badge-danger">{{ $errors->first('heart_surgery_name') }}</span>
                                    @endif

                                </div>


                            </div>

                            <div class="form-group row surgery-details" style="{{ old("had_heart_surgery") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Surgery Year
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Plese enter the year of the surgery"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control year-select" id="surgery-year" name="heart_surgery_year" data-placeholder="Choose ...">
                                        <option value="">Select Year</option>
                                        @for($i = 2019; $i > 1950; $i--)
                                            <option value="{{ $i }}" {{ old('heart_surgery_year')  == $i ? 'selected="selected"' : '' }}>{{ $i }}</option>
                                        @endfor
                                    </select>

{{--                                    <p>Please select the year you had heart surgery.</p>--}}

                                    @if ($errors->has('heart_surgery_year'))
                                        <span class="badge badge-danger">{{ $errors->first('heart_surgery_year') }}</span>
                                    @endif

                                </div>
                            </div>

                            <div class="form-group row surgery-details" style="{{ old("had_heart_surgery") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Stents Placed (optional)
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Plese enter how many stents were placed if applicable."></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control stent-select" id="stent-count" name="stents_placed" data-placeholder="Choose ...">
                                        <option value="">Select Number</option>
                                        @for($i = 0; $i < 25; $i++)
                                            <option value="{{ $i }}" {{ old('stents_placed') == $i ? 'selected="selected"' : '' }}>{{ $i }}</option>
                                        @endfor
                                    </select>

{{--                                    <p>Please select the number of stents placed.</p>--}}

                                    @if ($errors->has('stents_placed'))
                                        <span class="badge badge-danger">{{ $errors->first('stents_placed') }}</span>
                                    @endif

                                </div>
                            </div>


                            <div class="form-group row surgery-details" style="{{ old("had_heart_surgery") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Valves Placed
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Plese enter how many valves were placed if applicable."></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control valve-select" id="valves-placed" multiple="multiple" name="valves_placed[]" data-placeholder="Choose ...">
                                        <optgroup label=General>
                                            <option value="None" {{in_array("None", old("valves_placed") ?: []) ? "selected": ""}}>None</option>
                                            <option value="Mitral Valve" {{in_array("Mitral Valve", old("valves_placed") ?: []) ? "selected": ""}}>Mitral Valve</option>
                                            <option value="Tricuspid Valve" {{in_array("Tricuspid Valve", old("valves_placed") ?: []) ? "selected": ""}}>Tricuspid Valve</option>
                                            <option value="Pulmonary Valve" {{in_array("Pulmonary Valve", old("valves_placed") ?: []) ? "selected": ""}}>Pulmonary Valve</option>
                                            <option value="Aortic Valve" {{in_array("Aortic Valve", old("valves_placed") ?: []) ? "selected": ""}}>Aortic Valve</option>
                                        </optgroup>
                                    </select>

{{--                                    <p>Please select which valves were placed.</p>--}}

                                    @if ($errors->has('valves_placed'))
                                        <span class="badge badge-danger">{{ $errors->first('valves_placed') }}</span>
                                    @endif


                                </div>

                            </div>

{{--                            SURGERY DETAILS END    --}}


                            <hr>

                            <div class="row">
                                <div class="col-12">

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Do you get chest pains at rest or with exertion?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control chest-pain-select" id="chest-pain" name="chest_pain" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('chest_pain')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('chest_pain')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you experience pains in your chest.</p>--}}

                                            @if ($errors->has('chest_pain'))
                                                <span class="badge badge-danger">{{ $errors->first('chest_pain') }}</span>
                                            @endif

                                        </div>
                                    </div>


                                </div>
                            </div>

{{--                            CHEST PAIN DETAILS --}}
                            <div class="form-group row chest-pain-details" style="{{ old("chest_pain") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Cardiologist Name
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Plese enter the name of the surgery"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <input type="text" class="form-control" placeholder="Enter cardiologist name" id="heart-surgery-name" name="cardiologist_name" value="{{ old('cardiologist_name') }}">

{{--                                    <p>Please enter the name of your cardiologist.</p>--}}

                                    @if ($errors->has('cardiologist_name'))
                                        <span class="badge badge-danger">{{ $errors->first('cardiologist_name') }}</span>
                                    @endif

                                </div>


                            </div>

                            <div class="form-group row chest-pain-details" style="{{ old("chest_pain") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Have you informed primary care physician?</label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="chest-pain" name="informed_primary_care_physician" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Yes" {{ old('informed_primary_care_physician')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                        <option value="No" {{ old('informed_primary_care_physician')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                    </select>

{{--                                    <p>Please select whether you have informed your primary care physician</p>--}}

                                    @if ($errors->has('informed_primary_care_physician'))
                                        <span class="badge badge-danger">{{ $errors->first('informed_primary_care_physician') }}</span>
                                    @endif

                                </div>
                            </div>
{{--                            CHEST PAIN DETAILS END    --}}

                            <hr>

                            <div class="row">
                                <div class="col-12">
                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Do you have abnormal heart rhythm?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="heart-rhythm" name="have_abnormal_heart_rhythm" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_abnormal_heart_rhythm')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_abnormal_heart_rhythm')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you have an abnormal heart rhythm.</p>--}}

                                            @if ($errors->has('have_abnormal_heart_rhythm'))
                                                <span class="badge badge-danger">{{ $errors->first('have_abnormal_heart_rhythm') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align:center;">Have you had a heart attack?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="heart-attack" name="had_heart_attack" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('had_heart_attack')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('had_heart_attack')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you have had a heart attack.</p>--}}

                                            @if ($errors->has('had_heart_attack'))
                                                <span class="badge badge-danger">{{ $errors->first('had_heart_attack') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Do you have heart failure?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control heart-failure-select" id="heart-failure" name="have_heart_failure" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_heart_failure')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_heart_failure')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you have had heart failure.</p>--}}

                                            @if ($errors->has('had_heart_failure'))
                                                <span class="badge badge-danger">{{ $errors->first('had_heart_failure') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                </div>
                            </div>


                            <div class="form-group row heart-failure-details" style="{{ old("had_heart_failure") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Can you lie flat? (if no, how many pillows)</label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="heart-failure-pillows" name="able_to_lie_flat" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="0" {{ old('able_to_lie_flat')  == '0' ? 'selected="selected"' : '' }}>Yes</option>
                                        <option value="1" {{ old('able_to_lie_flat')  == '1' ? 'selected="selected"' : '' }}>1</option>
                                        <option value="2" {{ old('able_to_lie_flat')  == '2' ? 'selected="selected"' : '' }}>2</option>
                                        <option value="3" {{ old('able_to_lie_flat')  == '3' ? 'selected="selected"' : '' }}>3</option>
                                    </select>

{{--                                    <p>Please how many pillows are required to lay flat.</p>--}}

                                    @if ($errors->has('able_to_lie_flat'))
                                        <span class="badge badge-danger">{{ $errors->first('able_to_lie_flat') }}</span>
                                    @endif

                                </div>
                            </div>

                            <div class="form-group row heart-failure-details" style="{{ old("had_heart_failure") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Do you get swelling in your legs?</label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="heart-failure-swelling" name="swelling_in_legs" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Yes" {{ old('swelling_in_legs')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                        <option value="No" {{ old('swelling_in_legs')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                    </select>

{{--                                    <p>Please select whether you get swelling in your legs.</p>--}}

                                    @if ($errors->has('swelling_in_legs'))
                                        <span class="badge badge-danger">{{ $errors->first('swelling_in_legs') }}</span>
                                    @endif

                                </div>
                            </div>

                            <hr>


                            <div class="row">
                                <div class="col-12">

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Do you have valve disease? (if yes, which valve)</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="valve-disease" name="valve_disease[]" multiple="multiple" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="No" {{in_array("No", old("valve_disease") ?: []) ? "selected": ""}}>No</option>
                                                <option value="Aortic Valve" {{in_array("Aortic Valve", old("valve_disease") ?: []) ? "selected": ""}}>Aortic Valve</option>
                                                <option value="Tricuspid Valve" {{in_array("Tricuspid Valve", old("valve_disease") ?: []) ? "selected": ""}}>Tricuspid Valve</option>
                                                <option value="Mitral Valve" {{in_array("Mitral Valve", old("valve_disease") ?: []) ? "selected": ""}}>Mitral Valve</option>
                                                <option value="Pulmonic Valve" {{in_array("Pulmonic Valve", old("valve_disease") ?: []) ? "selected": ""}}>Pulmonic Valve</option>
                                            </select>

{{--                                            <p>Please select whether you've had valve disease. If you have not had valve disease, please select 'No'</p>--}}

                                            @if ($errors->has('valve_disease'))
                                                <span class="badge badge-danger">{{ $errors->first('valve_disease') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Are you on blood thinners?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="blood-thinners" name="on_blood_thinners" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('on_blood_thinners')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('on_blood_thinners')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you are on blood thinners.</p>--}}

                                            @if ($errors->has('on_blood_thinners'))
                                                <span class="badge badge-danger">{{ $errors->first('on_blood_thinners') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Have you had a stress test?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="stress-test" name="had_stress_test" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('had_stress_test')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('had_stress_test')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you have had a stress test.</p>--}}

                                            @if ($errors->has('had_stress_test'))
                                                <span class="badge badge-danger">{{ $errors->first('had_stress_test') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Have you had a catheterization?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="had-catherization" name="had_catherization" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('had_catherization')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('had_catherization')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you have had catherization.</p>--}}

                                            @if ($errors->has('had_catherization'))
                                                <span class="badge badge-danger">{{ $errors->first('had_catherization') }}</span>
                                            @endif

                                        </div>
                                    </div>

                                    <hr>

                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align: center;">Do you have a pacemaker?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control pace-maker-select" id="pace-maker-select" name="have_pacemaker" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_pacemaker')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_pacemaker')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

{{--                                            <p>Please select whether you use a pacemaker.</p>--}}

                                            @if ($errors->has('have_pacemaker'))
                                                <span class="badge badge-danger">{{ $errors->first('have_pacemaker') }}</span>
                                            @endif

                                        </div>
                                    </div>


                                </div>
                            </div>

{{--                            <div class="form-group row pace-maker-details" style="display:none">--}}
{{--                                <label for="example-text-input" class="col-sm-6 col-form-label">Please upload a picture of the pacemaker/defibrillator card</label>--}}
{{--                                <div class="col-sm-6">--}}
{{--                                    <div class="m-b-30 dropzone">--}}
{{--                                            <div class="fallback">--}}
{{--                                                <input name="file" type="file" multiple="multiple">--}}
{{--                                            </div>--}}
{{--                                    </div>--}}
{{--                                </div>--}}
{{--                            </div>--}}


                            <div class="row">
                                <div class="col-md-12">
                                    <button type="submit" class="btn btn-primary btn-flat pull-right">Submit</button>
                                </div>
                            </div>

                        </form>

                    </div>
                </div>
            </div>
            <div class="col-md-3 col-xl-3">
                <div class="card m-b-30">
                    <img class="card-img-top img-fluid" src="{{ asset('assets/images/h3a-logo-black.jpg') }}" alt="Card image cap">
                </div>
            </div>
        </div>
        <!-- end row -->

    </div>


</div> <!-- Page content Wrapper -->

</div> <!-- content -->

@include('forms/elements/footer_start')

<script src="{{ asset('assets/plugins/select2/js/select2.min.js') }}" type="text/javascript"></script>
<script src="{{ asset('assets/plugins/bootstrap-datepicker/js/bootstrap-datepicker.min.js') }}"></script>

<!-- Plugins Init js -->
<script src="{{ asset('assets/pages/form-advanced.js') }}"></script>

<script src="{{ asset('assets/plugins/dropzone/dist/dropzone.js') }}"></script>

<script>
    $(function () {

        $( ".heart-surgery-select").change(function() {
            if ($(".heart-surgery-select").val() === "Yes") {
                $(".surgery-details").slideDown();
            } else {
                $(".surgery-details").slideUp();
            }
        });

        $( ".chest-pain-select").change(function() {
            if ($(".chest-pain-select").val() === "Yes") {
                $(".chest-pain-details").slideDown();
            } else {
                $(".chest-pain-details").slideUp();
            }
        });

        $( ".heart-failure-select").change(function() {
            if ($(".heart-failure-select").val() === "Yes") {
                $(".heart-failure-details").slideDown();
            } else {
                $(".heart-failure-details").slideUp();
            }
        });

        $( ".pace-maker-select").change(function() {
            if ($(".pace-maker-select").val() === "Yes") {
                $(".pace-maker-details").slideDown();
            } else {
                $(".pace-maker-details").slideUp();
            }
        });
    });
    $(function(){
        $('#surgery_date').datepicker({
            format: "dd.mm.yyyy",
            todayBtn: "linked",
            language: "de"
        });

        $(".select2").select2();
    });

</script>

@include('forms/elements/footer_end')