@extends('layouts.app')

@section('content')
<style>
    .bdr-bot {
        border:none;
        border-radius: 0;
        border-bottom: 1px solid black;
    }
</style>
    <div class="card card-outline card-tabs">
        <div class="card-body">
            <div class="row p-2">
                <div class="col-3 p-1">
                    <h6>REFERRED TO:</h6>

                    <div class="d-flex">
                        <label>Facility:</label>

                        <input type="text" class="form-control bdr-bot">

                    </div>

                    <div class="d-flex">
                        <label>Date:</label>&emsp;&nbsp;
                        <input type="text" class="form-control bdr-bot">
                    </div>

                    <div class="d-flex mb-5">
                        <label>Time:</label>&emsp;
                        <input type="text" class="form-control bdr-bot">
                    </div>

                    <h6>REFERRED FROM:</h6>
                    <div class="d-flex">
                        <label >Facility:</label>

                        <input type="text" class="form-control bdr-bot" >

                    </div>

                    <div class="d-flex">
                        <label class="">Date:</label> &emsp;
                         
                        <input type="text" class="form-control bdr-bot"  >
                    </div>

                    <div class="d-flex mb-5">
                        <label>Time:</label>&emsp;
                         
                        <input type="text" class="form-control bdr-bot"  >
                    </div>

                    <h6>REASON FOR REFERRAL:</h6>
                    <div class="form-group clearfix">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason1">
                                Further evaluation and management
                            </label>
                        </div>
                    </div>
                    <div class="form-group clearfix">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason2">
                                For work-up
                            </label>
                        </div>
                    </div>
                    <div class="form-group clearfix">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason3">
                                For medico-legal
                            </label>
                        </div>
                    </div>
                    <div class="form-group clearfix">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason4">
                                Isolation
                            </label>
                        </div>
                    </div>
                    <div class="form-group clearfix">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason5">
                                Patient's request
                            </label>
                        </div>
                    </div>
                    <div class="form-group clearfix mb-5">
                        <div class="icheck-default d-inline">
                            <input type="radio"  >
                            <label for="reason6">
                                OPD Consult
                            </label>
                        </div>
                    </div>

                    <h6>PHILHEALTH INFORMATION:</h6>
                    <div class="form-group clearfix mb-3">
                        <div class="icheck-default d-inline">
                            <input type="radio" >
                            <label for="phealth1">
                                PHIC ID NO
                            </label>
                            <input type="text" class="form-control bdr-bot" >
                        </div>
                    </div>
                    <div class="form-group clearfix mb-5">
                        <div class="icheck-default d-inline">
                            <input type="radio" >
                            <label for="phealth2">
                                Non-PHIC
                            </label>
                        </div>
                    </div>

                    <h6>REFERRED BY:</h6>
                    <input type="text" class="form-control bdr-bot" >
                    <label class="font-italic">Printed Name & Signature</label>

                    <input type="text" class="form-control bdr-bot" >
                    <label class="font-italic">Designation</label>

                    <input type="text" class="form-control bdr-bot" >
                    <label class="font-italic">Contact No.</label>
                </div>

                <div class="col-9 p-1">
                    <div class="row">
                        <div class="col-3 text-right">
                            <img src="{{asset('dist/svg-files/pgno_logo_hd.png')}}" alt="pgno-log" class="brand-image img-circle w-50" >
                        </div>
                        <div class="col-6 text-center">
                            <p class="p-0 m-0">Republic of the Philippines</p>
                            <p class="p-0 m-0">Province of Negros Occidental</p>
                            <h4 class="p-0 m-0">{{$hospital->hospital}}</h4>
                            <h3 class="p-0 m-0">HEALTH REFERRAL FORM</h3>
                        </div>
                        <div class="col-3"></div>
                    </div>

                    <div class="px-5 pt-3">
                        <div class="d-flex mb-2">
                            <label for="">REFERRAL FORM #:</label>
                            <input type="text" class="form-control bdr-bot  text-nowrap" >
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">PATIENT NAME:</label>
                            <input type="text" class="form-control bdr-bot" >
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">AGE:</label>
                            <input type="text" class="form-control bdr-bot"  >

                            <label for="">SEX:</label>
                            <input type="text" class="form-control bdr-bot" >

                            <label for="">BIRTHDATE:</label>
                            <input type="text" class="form-control bdr-bot" >

                            <label for="">CIVIL STATUS:</label>
                            <input type="text" class="form-control bdr-bot text-nowrap"  ">
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">ADDRESS:</label>
                            <input type="text" class="form-control bdr-bot"  >
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">OCCUPATION:</label>
                            <input type="text" class="form-control bdr-bot"  >

                            <label for="">RELIGION:</label>
                            <input type="text" class="form-control bdr-bot" >
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">PARENT/GUARDIAN (in case of a minor):</label>
                            <input type="text" class="form-control bdr-bot"  >
                        </div>

                        <div class="d-flex mb-2">
                            <div class="form-group clearfix">
                                <div class="icheck-default d-inline">
                                    <input type="radio" id="state1" >
                                    <label for="state1">
                                        PWD
                                    </label>
                                </div>
                            </div>
                            &nbsp;&nbsp;&nbsp;&nbsp;
                            <div class="form-group clearfix">
                                <div class="icheck-default d-inline">
                                    <input type="radio" id="state2" >
                                    <label for="state2">
                                        SC
                                    </label>
                                </div>
                            </div>
                            &nbsp;&nbsp;&nbsp;&nbsp;
                            <div class="form-group clearfix">
                                <div class="icheck-default d-inline">
                                    <input type="radio" id="state3" >
                                    <label for="state3">
                                        IC
                                    </label>
                                </div>
                            </div>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">CHIEF COMPLAINT:</label>
                            <textarea style="border: 1px solid black" class="form-control" cols="30" rows="3"></textarea>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">VITAL SIGNS:</label>
                            <div class=" p-3 w-100 d-flex" style="border: 1px solid black">
                                <label for="">BP:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">HR:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">RR:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">Temp:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">Weight:</label>
                                <input type="text" class="form-control bdr-bot" >
                            </div>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">OB HISTORY:</label>
                            <div class="p-3 w-100" style="border: 1px solid black">
                                <div class="d-flex">
                                    <label for="">G:</label>
                                    <input type="text" class="form-control bdr-bot" >

                                    <label for="">P:</label>
                                    <input type="text" class="form-control bdr-bot" >

                                    <label for="">LMP:</label>
                                    <input type="text" class="form-control bdr-bot" ">

                                    <label for="">EDC:</label>
                                    <input type="text" class="form-control bdr-bot" >

                                    <label for="">AOG:</label>
                                    <input type="text" class="form-control bdr-bot" >
                                </div>

                                <div class="d-flex mt-2">
                                    <label for="">FH:</label>
                                    <input type="text" class="form-control bdr-bot" >

                                    <label for="">FHR:</label>
                                    <input type="text" class="form-control bdr-bot" >

                                    <label for="">Pelvic Exam:</label>
                                    <input type="text" class="form-control bdr-bot" >
                                </div>
                            </div>
                        </div>

                        <div class="d-flex mb-2">
                            <div class="p-3 w-100 d-flex">
                                <label for="">O2 SAT:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">REFERRAL TYPE:</label>
                                <input type="text" class="form-control bdr-bot" >

                                <label for="">RAT:</label>
                                <input type="text" class="form-control bdr-bot">

                                <label for="">RTPCR:</label>
                                <input type="text" class="form-control bdr-bot">

                                <label for="">VACCINATION:</label>
                                <input type="text" class="form-control bdr-bot">
                            </div>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">BRIEF HX AND PE:</label>
                            <textarea style="border: 1px solid black" class="form-control" cols="30" rows="5"></textarea>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">IMPRESSION/DIAGNOSIS: &nbsp;&nbsp;&nbsp;</label>
                            <textarea style="border: 1px solid black" class="form-control" cols="30" rows="6"></textarea>
                        </div>

                        <div class="d-flex mb-2">
                            <label for="">ACTION TAKEN / TREATMENT / MEDICATION GIVEN: &nbsp;&nbsp;&nbsp;</label>
                            <textarea style="border: 1px solid black" class="form-control" rows="7"></textarea>
                        </div>



                        <div class="d-flex mb-2">
                            <label for="">REMARKS: &nbsp;&nbsp;&nbsp;</label>
                            <textarea style="border: 1px solid black" class="form-control" rows="4"></textarea>
                        </div>


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

        <div class="card-footer text-center" id="referral_footer">
            <button class="btn btn-danger" id="referral_print">
                <i class="fa fa-print"></i> PRINT
            </button>
        </div>
    </div>
@endsection

@section('script')
<script>
    $(function(){
        $('#referral_print').click(function(e) {
            e.preventDefault();
            $('#referral_footer').hide()
            $('.main-footer').hide()
            window.print()
            $('#referral_footer').show()
            $('.main-footer').show()
        })
    })
</script>
@endsection