@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">Miscellaneous</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/Misc.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">
{{--    @include('patients.elements.list')--}}


    <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" data-toggle="modal" data-target="#myModal"><i class="fa fa-info-circle" style="font-size: 85px;"></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">95% 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="80" aria-valuemin="0" aria-valuemax="100" style="width: 80%"></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">Miscellaneous</h4>

                    <div class="card-body">

                        <form action="{{ isset($id) ?  route('patients.store.miscellaneous.answer', ['id' => $id]) :  route('patients.store.miscellaneous.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 use illegal drugs or Marijuana?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control drugs-select" id="question-bp" name="use_illegal_drugs" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="No" {{ old('use_illegal_drugs')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                                <option value="Marijuana" {{ old('use_illegal_drugs')  == 'Marijuana' ? 'selected="selected"' : '' }}>Marijuana</option>
                                                <option value="Yes" {{ old('use_illegal_drugs')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </div>
                            </div>

                            <div class="form-group row drugs-details" style="{{ old("use_illegal_drugs") === "Marijuana" ? '' : (old("use_illegal_drugs") === "Yes" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Which drugs?
                                </label>
                                <div class="col-sm-6">
                                    <input type="text" class="form-control" id="which_drugs" name="which_drugs" placeholder="please separate values with a comma ( , )">
                                </div>

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

                            </div>

                            <div class="form-group row drugs-details" style="{{ old("use_illegal_drugs") === "Marijuana" ? '' : (old("use_illegal_drugs") === "Yes" ? '' : 'display:none') }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">How often?
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="" name="drugs_how_often" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Once Weekly" {{ old('drink_how_often')  == 'Once Weekly' ? 'selected="selected"' : '' }}>Once Weekly</option>
                                        <option value="Twice Weekly" {{ old('drink_how_often')  == 'Twice Weekly' ? 'selected="selected"' : '' }}>Twice Weekly</option>
                                        <option value="Three Times Weekly" {{ old('drink_how_often')  == 'Three Times Weekly' ? 'selected="selected"' : '' }}>Three Times Weekly</option>
                                        <option value="Four Times Weekly" {{ old('drink_how_often')  == 'Four Times Weekly' ? 'selected="selected"' : '' }}>Four Times Weekly</option>
                                        <option value="Five Times Weekly" {{ old('drink_how_often')  == 'Five Times Weekly' ? 'selected="selected"' : '' }}>Five Times Weekly</option>
                                        <option value="Six Times Weekly" {{ old('drink_how_often')  == 'Six Times Weekly' ? 'selected="selected"' : '' }}>Six Times Weekly</option>
                                        <option value="Every Day" {{ old('drink_how_often')  == 'Every Day' ? 'selected="selected"' : '' }}>Every Day</option>
                                    </select>
                                </div>

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

                            </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 drink?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control alcohol-select" id="question-bp" name="do_you_drink" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('do_you_drink')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('do_you_drink')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </div>
                            </div>

                            <div class="form-group row alcohol-details" style="{{ old("do_you_drink") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">How much do you drink? (units)
                                </label>
                                <div class="col-sm-6">
                                    <div class="input-group">
                                        <input type="number" min="1" max="500" class="form-control" id="drink_how_often" name="drink_how_often"  placeholder="E.g. 4" value="{{ old('drink_how_often') }}">
                                    </div><!-- input-group -->

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


                            <div class="form-group row alcohol-details" style="{{ old("do_you_drink") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">How often do you drink?
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="" name="drink_how_often" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Once Weekly" {{ old('drink_how_often')  == 'Once Weekly' ? 'selected="selected"' : '' }}>Once Weekly</option>
                                        <option value="Twice Weekly" {{ old('drink_how_often')  == 'Twice Weekly' ? 'selected="selected"' : '' }}>Twice Weekly</option>
                                        <option value="Three Times Weekly" {{ old('drink_how_often')  == 'Three Times Weekly' ? 'selected="selected"' : '' }}>Three Times Weekly</option>
                                        <option value="Four Times Weekly" {{ old('drink_how_often')  == 'Four Times Weekly' ? 'selected="selected"' : '' }}>Four Times Weekly</option>
                                        <option value="Five Times Weekly" {{ old('drink_how_often')  == 'Five Times Weekly' ? 'selected="selected"' : '' }}>Five Times Weekly</option>
                                        <option value="Six Times Weekly" {{ old('drink_how_often')  == 'Six Times Weekly' ? 'selected="selected"' : '' }}>Six Times Weekly</option>
                                        <option value="Every Day" {{ old('drink_how_often')  == 'Every Day' ? 'selected="selected"' : '' }}>Every Day</option>
                                    </select>

                                    @if ($errors->has('drink_how_often'))
                                        <span class="badge badge-danger">{{ $errors->first('drink_how_often') }}</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 take pain medication?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control pain-medication-select" id="question-bp" name="take_pain_medication" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('take_pain_medication')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('take_pain_medication')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </div>
                            </div>

                            <div class="form-group row pain-medication-details" style="{{ old("take_pain_medication") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">How often do you take pain medication?
                                </label>
                                <div class="col-sm-6">
                                    <select class="select2 form-control" id="" name="pain_med_how_often" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Once Weekly" {{ old('pain_med_how_often')  == 'Once Weekly' ? 'selected="selected"' : '' }}>Once Weekly</option>
                                        <option value="Twice Weekly" {{ old('pain_med_how_often')  == 'Twice Weekly' ? 'selected="selected"' : '' }}>Twice Weekly</option>
                                        <option value="Three Times Weekly" {{ old('pain_med_how_often')  == 'Three Times Weekly' ? 'selected="selected"' : '' }}>Three Times Weekly</option>
                                        <option value="Four Times Weekly" {{ old('pain_med_how_often')  == 'Four Times Weekly' ? 'selected="selected"' : '' }}>Four Times Weekly</option>
                                        <option value="Five Times Weekly" {{ old('pain_med_how_often')  == 'Five Times Weekly' ? 'selected="selected"' : '' }}>Five Times Weekly</option>
                                        <option value="Six Times Weekly" {{ old('pain_med_how_often')  == 'Six Times Weekly' ? 'selected="selected"' : '' }}>Six Times Weekly</option>
                                        <option value="Every Day" {{ old('pain_med_how_often')  == 'Every Day' ? 'selected="selected"' : '' }}>Every Day</option>
                                    </select>

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

        $( ".drugs-select" ).change(function() {
            if ($(".drugs-select").val() !== "No") {
                $(".drugs-details").slideDown();
            } else {
                $(".drugs-details").slideUp();
            }
        });
        $( ".alcohol-select" ).change(function() {
            if ($(".alcohol-select").val() === "Yes") {
                $(".alcohol-details").slideDown();
            } else {
                $(".alcohol-details").slideUp();
            }
        });
        $( ".pain-medication-select" ).change(function() {
            if ($(".pain-medication-select").val() === "Yes") {
                $(".pain-medication-details").slideDown();
            } else {
                $(".pain-medication-details").slideUp();
            }
        });

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

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

</script>

@include('forms/elements/footer_end')