@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">Endocrine</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/Endocrine.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">70% 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="70" aria-valuemin="0" aria-valuemax="100" style="width: 70%"></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">Endocrine</h4>

                    <div class="card-body">

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

{{--                            QUESTION 1    --}}
                            <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 any endocrine disorders?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control endocrine-select" id="endocrine-disorders" name="have_endocrine_disorders[]" multiple="multiple" data-placeholder="Choose ...">
                                                <option value="No" {{in_array("No", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>No</option>
                                                <option value="Type 1 Diabetes" {{in_array("Type 1 Diabetes", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Type 1 Diabetes</option>
                                                <option value="Type 2 Diabetes" {{in_array("Type 2 Diabetes", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Type 2 Diabetes</option>
                                                <option value="Osteoporosis" {{in_array("Osteoporosis", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Osteoporosis</option>
                                                <option value="Thyroid Cancer" {{in_array("Thyroid Cancer", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Thyroid Cancer</option>
                                                <option value="Addison's Disease" {{in_array("Addison's Disease", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Addison's Disease</option>
                                                <option value="Cushing's Syndrome" {{in_array("Cushing's Syndrome", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Cushing's Syndrome</option>
                                                <option value="Graves' Disease" {{in_array("Graves' Disease", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Graves' Disease</option>
                                                <option value="Hashimoto's Thyroiditis" {{in_array("Hashimoto's Thyroiditis", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>Hashimoto's Thyroiditis</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </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 diabetes?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control diabetes-select" id="diabetes" name="have_diabetes" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="No" {{ old('have_diabetes')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                                <option value="Type 1" {{ old('have_diabetes')  == 'Type 1' ? 'selected="selected"' : '' }}>Type 1</option>
                                                <option value="Type 2" {{ old('have_diabetes')  == 'Type 2' ? 'selected="selected"' : '' }}>Type 2</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </div>
                            </div>


                            <div class="form-group row diabetes-details" style="{{ old("have_diabetes") === "Type 1" ? '' : (old("have_diabetes") === "Type 2" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">What insulin type?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="insulin-type" name="insulin_type" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="None" {{ old('insulin_type')  == 'None' ? 'selected="selected"' : '' }}>None</option>
                                        <option value="Humalog" {{ old('insulin_type')  == 'Humalog' ? 'selected="selected"' : '' }}>Humalog</option>
                                        <option value="Lantus" {{ old('insulin_type')  == 'Lantus' ? 'selected="selected"' : '' }}>Lantus</option>
                                        <option value="Levemir" {{ old('insulin_type')  == 'Levemir' ? 'selected="selected"' : '' }}>Levemir</option>
                                        <option value="Novorapid" {{ old('insulin_type')  == 'Novorapid' ? 'selected="selected"' : '' }}>Novorapid</option>
                                    </select>

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

                                </div>

                            </div>

                            <div class="form-group row diabetes-details" style="{{ old("have_diabetes") === "Type 1" ? '' : (old("have_diabetes") === "Type 2" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">What is your average glucose reading?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="glucose-reading" name="avg_glucose_reading" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="90" {{ old('avg_glucose_reading')  == '90' ? 'selected="selected"' : '' }}>90 mg/dL</option>
                                        <option value="100" {{ old('avg_glucose_reading')  == '100' ? 'selected="selected"' : '' }}>100 mg/dL</option>
                                        <option value="110" {{ old('avg_glucose_reading')  == '110' ? 'selected="selected"' : '' }}>110 mg/dL</option>
                                        <option value="120" {{ old('avg_glucose_reading')  == '120' ? 'selected="selected"' : '' }}>120 mg/dL</option>
                                        <option value="130" {{ old('avg_glucose_reading')  == '130' ? 'selected="selected"' : '' }}>130 mg/dL</option>
                                        <option value="140" {{ old('avg_glucose_reading')  == '140' ? 'selected="selected"' : '' }}>140 mg/dL</option>
                                    </select>

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

                            </div>

                            <div class="form-group row diabetes-details" style="{{ old("have_diabetes") === "Type 1" ? '' : (old("have_diabetes") === "Type 2" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">When was your last HA1C test?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <div class="input-group">
                                        <input type="text" class="form-control" placeholder="Select from calendar" id="last-h1ac" name="last_h1ac_test" value="{{ old('last_h1ac_test') }}">
                                        <div class="input-group-append">
                                            <span class="input-group-text"><i class="mdi mdi-calendar"></i></span>
                                        </div>
                                    </div><!-- input-group -->

                                    @if ($errors->has('last_h1ac_test'))
                                        <span class="badge badge-danger">{{ $errors->first('last_h1ac_test') }}</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;">Hypo or hyperthyroidism?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control hypo-select" id="hypo" name="hypo" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="None">None</option>
                                                <option value="Hypo" {{ old('hypo')  == 'Hypo' ? 'selected="selected"' : '' }}>Hypo</option>
                                                <option value="Hyperthyroidism" {{ old('hypo')  == 'Hyperthyroidism' ? 'selected="selected"' : '' }}>Hyperthyroidism</option>
                                            </select>

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

                                </div>
                            </div>


                            <div class="form-group row hypo-details" style="{{ old("hypo") === "Hypo" ? '' : (old("hypo") === "Hyperthyroidism" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">When was your last TSH?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <div class="input-group">
                                        <input type="text" class="form-control" placeholder="Select from calendar" id="last-tsh" name="last_tsh" value="{{ old('last_tsh') }}">
                                        <div class="input-group-append">
                                            <span class="input-group-text"><i class="mdi mdi-calendar"></i></span>
                                        </div>
                                    </div><!-- input-group -->

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


                            <div class="form-group row hypo-details" style="{{ old("hypo") === "Hypo" ? '' : (old("hypo") === "Hyperthyroidism" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Do you have Rheumatoid arthritis?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control arthiritis-select" id="arthiritis" name="have_arthiritis" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Yes" {{ old('have_arthiritis')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                        <option value="No" {{ old('have_arthiritis')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                    </select>

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

                            <div class="form-group row hypo-details" style="{{ old("hypo") === "Hypo" ? '' : (old("hypo") === "Hyperthyroidism" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Do you take steroids?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control arthiritis-select" id="arthiritis" name="take_steroids" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Yes" {{ old('take_steroids')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                        <option value="No" {{ old('take_steroids')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                    </select>

                                    @if ($errors->has('take_steroids'))
                                        <span class="badge badge-danger">{{ $errors->first('take_steroids') }}</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 Lupus?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control" id="" name="have_lupus" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_lupus')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_lupus')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

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

                                </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 any blood disorders?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control" id="" name="blood_disorders[]" multiple="multiple" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="None" {{ old('blood_disorders')  == 'None' ? 'selected="selected"' : '' }}>None</option>
                                                <option value="Anemia" {{ old('blood_disorders')  == 'Anemia' ? 'selected="selected"' : '' }}>Anemia</option>
                                                <option value="Hemophilia" {{ old('blood_disorders')  == 'Hemophilia' ? 'selected="selected"' : '' }}>Hemophilia</option>
                                                <option value="Blood Clots" {{ old('blood_disorders')  == 'Blood Clots' ? 'selected="selected"' : '' }}>Blood Clots</option>
                                                <option value="Leukemia" {{ old('blood_disorders')  == 'Leukemia' ? 'selected="selected"' : '' }}>Leukemia</option>
                                                <option value="Lymphoma" {{ old('blood_disorders')  == 'Lymphoma' ? 'selected="selected"' : '' }}>Lymphoma</option>
                                                <option value="Myeloma" {{ old('blood_disorders')  == 'Myeloma' ? 'selected="selected"' : '' }}>Myeloma</option>
                                            </select>

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

                                </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 HIV/Aids?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control hiv-select" id="" name="have_hiv_aids" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="No" {{ old('have_hiv_aids')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                                <option value="HIV" {{ old('have_hiv_aids')  == 'HIV' ? 'selected="selected"' : '' }}>HIV</option>
                                                <option value="Aids" {{ old('have_hiv_aids')  == 'Aids' ? 'selected="selected"' : '' }}>Aids</option>
                                            </select>

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

                                </div>
                            </div>


                            <div class="form-group row hiv-details" style="{{ old("have_hiv_aids") === "No" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">When was your most recent CD4 count?
{{--                                    <i class="ion-help-circled" rel="tooltip" title="Select active status" data-content="Please enter how often you use your rescue inhaler"></i>--}}
                                </label>
                                <div class="col-sm-6">
                                    <div class="input-group">
                                        <input type="text" class="form-control" placeholder="Select from calendar" id="last-dc4" name="last_dc4_test" value="{{ old('last_dc4_test') }}">
                                        <div class="input-group-append">
                                            <span class="input-group-text"><i class="mdi mdi-calendar"></i></span>
                                        </div>
                                    </div><!-- input-group -->

                                    @if ($errors->has('last_dc4_test'))
                                        <span class="badge badge-danger">{{ $errors->first('last_dc4_test') }}</span>
                                    @endif

                                </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 () {

        $( ".diabetes-select" ).change(function() {
            if ($(".diabetes-select").val() !== "No") {
                $(".diabetes-details").slideDown();
            } else {
                $(".diabetes-details").slideUp();
            }
        });

        $( ".hypo-select" ).change(function() {
            if ($(".hypo-select").val() !== "None") {
                $(".hypo-details").slideDown();
            } else {
                $(".hypo-details").slideUp();
            }
        });

        $( ".arthiritis-select" ).change(function() {
            if ($(".arthiritis-select").val() !== "No") {
                $(".arthiritis-details").slideDown();
            } else {
                $(".arthiritis-details").slideUp();
            }
        });

        $( ".hiv-select" ).change(function() {
            if ($(".hiv-select").val() !== "No") {
                $(".hiv-details").slideDown();
            } else {
                $(".hiv-details").slideUp();
            }
        });

    });
    $(function(){
        $('#last-h1ac').datepicker({
            format: "mm/dd/yyyy",
            language: "en"
        });
        $('#last-tsh').datepicker({
            format: "mm/dd/yyyy",
            language: "en"
        });
        $('#last-dc4').datepicker({
            format: "mm/dd/yyyy",
            language: "en"
        });

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

</script>

@include('forms/elements/footer_end')