@extends('admin.layouts.app')

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

@section('header')
Edit Patient
@endsection

@section('content')

<form method="POST" action="{{ route('admin.patients.update',$patient) }}">
@csrf
@method('PUT')

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

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

    <div class="card-body">

        <div class="row">

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

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

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

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

                <label>Gender</label>

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

                    <option value="Male"
                        @selected(old('gender',$patient->gender)=='Male')>
                        Male
                    </option>

                    <option value="Female"
                        @selected(old('gender',$patient->gender)=='Female')>
                        Female
                    </option>

                </select>

            </div>

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

                <label>Date of Birth</label>

                <input
                    type="date"
                    name="date_of_birth"
                    class="form-control"
                    value="{{ old('date_of_birth', optional($patient->date_of_birth)->format('Y-m-d')) }}">

            </div>

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

                <label>National ID</label>

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

            </div>

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

                <label>Marital Status</label>

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

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

                    <option value="Single"
                        @selected(old('marital_status',$patient->marital_status)=='Single')>
                        Single
                    </option>

                    <option value="Married"
                        @selected(old('marital_status',$patient->marital_status)=='Married')>
                        Married
                    </option>

                    <option value="Divorced"
                        @selected(old('marital_status',$patient->marital_status)=='Divorced')>
                        Divorced
                    </option>

                    <option value="Widowed"
                        @selected(old('marital_status',$patient->marital_status)=='Widowed')>
                        Widowed
                    </option>

                </select>

            </div>

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

                <label>Phone</label>

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

            </div>

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

                <label>Email</label>

                <input
                    type="email"
                    name="email"
                    class="form-control"
                    value="{{ old('email',$patient->email) }}">

            </div>

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

                <label>Address</label>

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

            </div>

        </div>

    </div>

</div>

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

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

    <div class="card-body">

        <div class="row">

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

                <label>Blood Group</label>

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

                    @foreach(['A+','A-','B+','B-','AB+','AB-','O+','O-'] as $bg)
                        <option value="{{ $bg }}"
                            @selected(old('blood_group',$patient->blood_group)==$bg)>
                            {{ $bg }}
                        </option>
                    @endforeach

                </select>

            </div>

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

                <label>Height (cm)</label>

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

            </div>

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

                <label>Weight (kg)</label>

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

            </div>

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

                <label>Allergies</label>

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

            </div>

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

                <label>Chronic Diseases</label>

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

            </div>

        </div>

    </div>

</div>

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

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

    <div class="card-body">

        <div class="row">

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

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

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

        </div>

    </div>

</div>

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

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

    <div class="card-body">

        <div class="row">

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

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

        </div>

    </div>

</div>

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

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

    <div class="card-body">

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

    </div>

</div>

<button type="submit" class="btn btn-primary">
    Update Patient
</button>

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

</form>

@endsection