@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">Neurological</h2>
    </li>
</ul>

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

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

<!-- ==================
     PAGE CONTENT START
     ================== -->

<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 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">80% 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">Neurological</h4>

                    <div class="card-body">

                        <form action="{{ isset($id) ?  route('patients.store.neurological.answer', ['id' => $id]) :  route('patients.store.neurological.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;">Have you had a stroke?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control stroke-select" id="question-bp" name="had_stroke" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('had_stroke')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('had_stroke')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

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

                                        </div>
                                    </div>

                                </div>
                            </div>

                            <div class="form-group row stroke-details" style="{{ old("had_stroke") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">When did you have a stroke?
{{--                                    <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="date-of-stroke" name="date_of_stroke" value="{{ old('date_of_stroke') }}">
                                        <div class="input-group-append">
                                            <span class="input-group-text"><i class="mdi mdi-calendar"></i></span>
                                        </div>
                                    </div><!-- input-group -->

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

                            <div class="form-group row stroke-details" style="{{ old("had_stroke") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">Do you still feel weakness in any parts of your body?
{{--                                    <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="stroke_weakness_where[]" multiple="multiple" data-placeholder="Choose ...">
                                        <option value="">Select</option>

                                        <option value="None" {{in_array("None", old("stroke_weakness_where") ?: []) ? "selected": ""}}>None</option>
                                        <option value="Arms" {{in_array("Arms", old("stroke_weakness_where") ?: []) ? "selected": ""}}>Arms</option>
                                        <option value="Hands" {{in_array("Hands", old("stroke_weakness_where") ?: []) ? "selected": ""}}>Hands</option>
                                        <option value="Legs" {{in_array("Legs", old("stroke_weakness_where") ?: []) ? "selected": ""}}>Legs</option>
                                        <option value="Feet" {{in_array("Feet", old("stroke_weakness_where") ?: []) ? "selected": ""}}>Feet</option>
                                    </select>

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

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

                                        </div>
                                    </div>

                                </div>
                            </div>


                            <div class="form-group row seizure-details" style="{{ old("get_seizures") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">When was your last seizure?
{{--                                    <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="date-of-seizure" name="date_of_seizure" value="{{ old('date_of_seizure') }}">
                                        <div class="input-group-append">
                                            <span class="input-group-text"><i class="mdi mdi-calendar"></i></span>
                                        </div>
                                    </div><!-- input-group -->

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


                            <div class="form-group row seizure-details" style="{{ old("get_seizures") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">What type of seizure?
{{--                                    <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="" name="type_of_seizure" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Absence" {{ old('type_of_seizure')  == 'Absence' ? 'selected="selected"' : '' }}>Absence</option>
                                        <option value="Tonic-Clonic" {{ old('type_of_seizure')  == 'Tonic-Clonic' ? 'selected="selected"' : '' }}>Tonic-Clonic</option>
                                        <option value="Convulsive" {{ old('type_of_seizure')  == 'Convulsive' ? 'selected="selected"' : '' }}>Convulsive</option>
                                        <option value="Atonic" {{ old('type_of_seizure')  == 'Atonic' ? 'selected="selected"' : '' }}>Atonic</option>
                                        <option value="Clonic" {{ old('type_of_seizure')  == 'Clonic' ? 'selected="selected"' : '' }}>Clonic</option>
                                        <option value="Tonic" {{ old('type_of_seizure')  == 'Tonic' ? 'selected="selected"' : '' }}>Tonic</option>
                                        <option value="Myoclonic" {{ old('type_of_seizure')  == 'Myoclonic' ? 'selected="selected"' : '' }}>Myoclonic</option>
                                    </select>

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

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

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

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

                                        </div>
                                    </div>

                                </div>
                            </div>

                            <div class="form-group row dementia-details" style="{{ old("have_dementia") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">How long have you had dementia?
{{--                                    <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="" name="how_long_had_dementia" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="1 year" {{ old('how_long_had_dementia')  == '1 year' ? 'selected="selected"' : '' }}>1 year</option>
                                        <option value="2 years" {{ old('how_long_had_dementia')  == '2 years' ? 'selected="selected"' : '' }}>2 years</option>
                                        <option value="3 years" {{ old('how_long_had_dementia')  == '3 years' ? 'selected="selected"' : '' }}>3 years</option>
                                        <option value="4 years" {{ old('how_long_had_dementia')  == '4 years' ? 'selected="selected"' : '' }}>4 years</option>
                                        <option value="5 years" {{ old('how_long_had_dementia')  == '5 years' ? 'selected="selected"' : '' }}>5 years</option>
                                        <option value="6 years" {{ old('how_long_had_dementia')  == '6 years' ? 'selected="selected"' : '' }}>6 years</option>
                                        <option value="7 years" {{ old('how_long_had_dementia')  == '7 years' ? 'selected="selected"' : '' }}>7 years</option>
                                        <option value="8 years" {{ old('how_long_had_dementia')  == '8 years' ? 'selected="selected"' : '' }}>8 years</option>
                                        <option value="9 years" {{ old('how_long_had_dementia')  == '9 years' ? 'selected="selected"' : '' }}>9 years</option>
                                        <option value="10+ years" {{ old('how_long_had_dementia')  == '10+ years' ? 'selected="selected"' : '' }}>10+ years</option>
                                    </select>

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

                                </div>

                            </div>

                            <div class="form-group row dementia-details" style="{{ old("have_dementia") === "Yes" ? '' : 'display:none' }}">
                                <label for="example-text-input" class="col-sm-6 col-form-label">What stage is your dementia at?
{{--                                    <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="" name="dementia_stage" data-placeholder="Choose ...">
                                        <option value="">Select</option>
                                        <option value="Stage 1" {{ old('how_long_had_dementia')  == 'Stage 1' ? 'selected="selected"' : '' }}>Stage 1: No cognitive decline</option>
                                        <option value="Stage 2" {{ old('how_long_had_dementia')  == 'Stage 2' ? 'selected="selected"' : '' }}>Stage 2: Very mild cognitive decline</option>
                                        <option value="Stage 3" {{ old('how_long_had_dementia')  == 'Stage 3' ? 'selected="selected"' : '' }}>Stage 3: Mild cognitive decline</option>
                                        <option value="Stage 4" {{ old('how_long_had_dementia')  == 'Stage 4' ? 'selected="selected"' : '' }}>Stage 4: Moderate cognitive decline</option>
                                        <option value="Stage 5" {{ old('how_long_had_dementia')  == 'Stage 5' ? 'selected="selected"' : '' }}>Stage 5: Moderately severe cognitive decline</option>
                                        <option value="Stage 6" {{ old('how_long_had_dementia')  == 'Stage 6' ? 'selected="selected"' : '' }}>Stage 6: Severe cognitive decline (Middle Dementia)</option>
                                        <option value="Stage 7" {{ old('how_long_had_dementia')  == 'Stage 7' ? 'selected="selected"' : '' }}>Stage 7: Very severe cognitive decline (Late Dementia)</option>
                                    </select>

                                    @if ($errors->has('dementia_stage'))
                                        <span class="badge badge-danger">{{ $errors->first('dementia_stage') }}</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 any psychiatric disorders?</label>
                                        <div class="col-sm-6 offset-sm-3">
                                            <select class="select2 form-control" id="" name="psychiatric_disorders[]" multiple="multiple" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="No" {{in_array("No", old("have_endocrine_disorders") ?: []) ? "selected": ""}}>No</option>
                                                <option value="Anger" {{in_array("Anger", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Anger</option>
                                                <option value="Sadness" {{in_array("Sadness", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Sadness</option>
                                                <option value="Anxiety" {{in_array("Anxiety", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Anxiety</option>
                                                <option value="Panic Attacks" {{in_array("Panic Attacks", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Panic Attacks</option>
                                                <option value="Bipolar Disorder" {{in_array("Bipolar Disorder", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Bipolar Disorder</option>
                                                <option value="Body Dismorphic Disorder" {{in_array("Body Dismorphic Disorder", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Body Dismorphic Disorder</option>
                                                <option value="Borderline Personality Disorder" {{in_array("Borderline Personality Disorder", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Borderline Personality Disorder</option>
                                                <option value="Depression" {{in_array("Depression", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Depression</option>
                                                <option value="Dissociative Disorder" {{in_array("Dissociative Disorder", old("psychiatric_disorders") ?: []) ? "selected": ""}}>Dissociative Disorder</option>
                                            </select>

                                            @if ($errors->has('psychiatric_disorders'))
                                                <span class="badge badge-danger">{{ $errors->first('psychiatric_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 suffer from depression?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="" name="have_depression" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_depression')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_depression')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

                                            @if ($errors->has('have_depression'))
                                                <span class="badge badge-danger">{{ $errors->first('have_depression') }}</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 suffer from anxiety?</label>
                                        <div class="col-sm-4 offset-sm-4">
                                            <select class="select2 form-control" id="" name="have_anxiety" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                <option value="Yes" {{ old('have_anxiety')  == 'Yes' ? 'selected="selected"' : '' }}>Yes</option>
                                                <option value="No" {{ old('have_anxiety')  == 'No' ? 'selected="selected"' : '' }}>No</option>
                                            </select>

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

                                        </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 () {

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


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

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

</script>

@include('forms/elements/footer_end')