@extends('admin.layouts.app')

@section('content')

<div class="col-12 grid-margin stretch-card">
    <div class="card">
        <div class="card-body">
            <h4 class="card-title">Edit Patient</h4>
            <p class="card-description">
            </p>
            <form id="add_patient" class="forms-sample" method="post" action="{{ route('admin.patient.update', $Patientdata->patient_id) }}">
           
            @csrf
            @method('put')
                <div class="row">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="first_name" class="form-label required">First Name </label>
                            <input type="text" class="form-control @error('first_name') is-invalid @enderror" name="first_name" value="{{$Patientdata->first_name}}">
                            @error('first_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="last_name" class="form-label required">Last Name</label>
                            <input type="text" class="form-control @error('last_name') is-invalid @enderror" name="last_name" value="{{ $Patientdata->last_name }}">
                            @error('last_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="middle_name" class="form-label required">Middle Name</label>
                            <input type="text" class="form-control @error('middle_name') is-invalid @enderror" name="middle_name" value="{{ $Patientdata->middle_name }}">
                            @error('middle_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="date_of_birth" class="form-label required">Date of Birth</label>
                            <input type="date" class="form-control @error('date_of_birth') is-invalid @enderror" name="date_of_birth" value="{{ $Patientdata->date_of_birth }}">
                            @error('date_of_birth')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>


                        <div class="form-group">
                            <label for="sex" class="form-label required">Gender</label>
                            <select class="form-select @error('sex') is-invalid @enderror" name="sex">
                                <option value="">Select Gender</option>
                                <option value="Male" {{ $Patientdata->sex == 'Male' ? 'selected' : '' }}>Male</option>
                                <option value="Female" {{$Patientdata->sex == 'Female' ? 'selected' : '' }}>Female</option>
                                <option value="Other" {{ $Patientdata->sex == 'Other' ? 'selected' : '' }}>Other</option>
                            </select>
                            @error('sex')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="address" class="form-label required">Address</label>
                            <input type="text" class="form-control @error('address') is-invalid @enderror" name="address" value="{{ $Patientdata->address }}">
                            @error('address')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="patient_phone_num_country_code" class="form-label required">Phone Number (Country Code)</label>
                            <input type="hidden" id="hidden_patient_phone_num_country_code" name="patient_phone_num_country_code" value="{{$Patientdata->patient_phone_num_country_code}}">

                            <input type="text" id="patient_phone_num_country_code " disabled class="form-control @error('patient_phone_num_country_code') is-invalid @enderror" value="{{$Patientdata->patient_phone_num_country_code}}">
                            @error('patient_phone_num_country_code')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="patient_phone_number" class="form-label required">Phone Number</label>

                            <input type="text" class="form-control @error('patient_phone_number') is-invalid @enderror" name="patient_phone_number" value="{{ $Patientdata->patient_phone_number  }}">
                            @error('patient_phone_number')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="patient_er_country_code" class="form-label required">Emergency Phone Number (Country Code)</label>
                            <input type="text" id="patient_er_country_code" class="form-control @error('patient_er_country_code') is-invalid @enderror" name="patient_er_country_code" maxlength="4" value="{{ $Patientdata->patient_er_country_code }}">
                            @error('patient_er_country_code')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="patient_er_phone_number" class="form-label required">Emergency Phone Number</label>
                            <input type="text" class="form-control @error('patient_er_phone_number') is-invalid @enderror" name="patient_er_phone_number" value="{{ $Patientdata->patient_er_phone_number }}">
                            @error('patient_er_phone_number')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="aadhar_card_num" class="form-label required">Aadhar Card Number Last 4 Digits.</label>
                            <input type="text" class="form-control @error('aadhar_card_num') is-invalid @enderror" name="aadhar_card_num" maxlength="4" value="{{ $Patientdata->aadhar_card_num }}">
                            @error('aadhar_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        
                       <div class="form-group">
                          <label for="blood_group" class="form-label">Blood Group (Optional)</label>
                          <div class="row">
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_a_positive" name="blood_group" value="A+" {{ $Patientdata->blood_group == 'A+' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_a_positive">A+</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_a_negative" name="blood_group" value="A-" {{ $Patientdata->blood_group == 'A-' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_a_negative">A-</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_b_positive" name="blood_group" value="B+" {{ $Patientdata->blood_group == 'B+' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_b_positive">B+</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_b_negative" name="blood_group" value="B-" {{ $Patientdata->blood_group == 'B-' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_b_negative">B-</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_ab_positive" name="blood_group" value="AB+" {{ $Patientdata->blood_group == 'AB+' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_ab_positive">AB+</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_ab_negative" name="blood_group" value="AB-" {{ $Patientdata->blood_group == 'AB-' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_ab_negative">AB-</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_o_positive" name="blood_group" value="O+" {{ $Patientdata->blood_group == 'O+' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_o_positive">O+</label>
                                  </div>
                              </div>
                              <div class="col-md-3">
                                  <div class="form-check">
                                      <input type="radio" class="form-check-input" id="blood_group_o_negative" name="blood_group" value="O-" {{ $Patientdata->blood_group == 'O-' ? 'checked' : '' }}>
                                      <label class="form-check-label" for="blood_group_o_negative">O-</label>
                                  </div>
                              </div>
                          </div>
                          @error('blood_group')
                          <span class="text-danger">{{ $message }}</span>
                          @enderror
                      </div>

                                
                        <div class="form-group">
                            <label for="pan_card_num" class="form-label required">PAN Card Number</label>
                            <input type="text" class="form-control @error('pan_card_num') is-invalid @enderror" name="pan_card_num" maxlength="20" value="{{ $Patientdata->pan_card_num }}">
                            @error('pan_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="ssn_card_num" class="form-label required">SSN Card Number</label>
                            <input type="text" class="form-control @error('ssn_card_num') is-invalid @enderror" name="ssn_card_num" maxlength="20" value="{{ $Patientdata->ssn_card_num }}">
                            @error('ssn_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="cibil_score" class="form-label required">CIBIL Score</label>
                            <input type="number" class="form-control @error('cibil_score') is-invalid @enderror" name="cibil_score" min="0" max="999" value="{{ $Patientdata->cibil_score }}">
                            @error('cibil_score')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="profession" class="form-label required">Profession</label>
                            <input type="text" class="form-control @error('profession') is-invalid @enderror" name="profession" value="{{ $Patientdata->profession }}">
                            @error('profession')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="employment_status" class="form-label required">Employment Status</label>
                            <input type="text" class="form-control @error('employment_status') is-invalid @enderror" name="employment_status" value="{{ $Patientdata->employment_status }}">
                            @error('employment_status')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                    </div>
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="marital_status" class="form-label required">Marital Status</label>
                            <input type="text" class="form-control @error('marital_status') is-invalid @enderror" name="marital_status" value="{{ $Patientdata->marital_status }}">
                            @error('marital_status')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="father_name" class="form-label required">Father's Name</label>
                            <input type="text" class="form-control @error('father_name') is-invalid @enderror" name="father_name" value="{{ $Patientdata->father_name }}">
                            @error('father_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="mother_name" class="form-label required">Mother's Name</label>
                            <input type="text" class="form-control @error('mother_name') is-invalid @enderror" name="mother_name" value="{{ $Patientdata->mother_name }}">
                            @error('mother_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="male_siblings" class="form-label required">Number of Male Siblings</label>
                            <input type="number" class="form-control @error('male_siblings') is-invalid @enderror" name="male_siblings" min="0" value="{{ $Patientdata->male_siblings }}">
                            @error('male_siblings')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>


                        <div class="form-group">
                            <label for="female_siblings" class="form-label required">Number of Female Siblings</label>
                            <input type="number" class="form-control @error('female_siblings') is-invalid @enderror" name="female_siblings" min="0" value="{{ $Patientdata->female_siblings }}">
                            @error('female_siblings')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="consent_to_contact" class="form-label required">Consent to Contact</label>
                            <select class="form-select @error('consent_to_contact') is-invalid @enderror" name="consent_to_contact">
                                <option value="1" {{ $Patientdata->consent_to_contact == '1' ? 'selected' : '' }}>Yes</option>
                                <option value="0" {{ $Patientdata->consent_to_contact == '0' ? 'selected' : '' }}>No</option>
                            </select>
                            @error('consent_to_contact')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="medical_billing_address" class="form-label required">Medical Billing Address</label>
                            <input type="text" class="form-control @error('medical_billing_address') is-invalid @enderror" name="medical_billing_address" value="{{ $Patientdata->medical_billing_address }}">
                            @error('medical_billing_address')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="current_medications" class="form-label required">Current Medications</label>
                            <input type="text" class="form-control @error('current_medications') is-invalid @enderror" name="current_medications" value="{{ $Patientdata->current_medications }}">
                            @error('current_medications')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="previous_health_history" class="form-label required">Previous Health History</label>
                            <input type="text" class="form-control @error('previous_health_history') is-invalid @enderror" name="previous_health_history" value="{{ $Patientdata->previous_health_history }}">
                            @error('previous_health_history')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="consent_to_treatment" class="form-label required">Consent to Treatment</label>
                            <select class="form-select @error('consent_to_treatment') is-invalid @enderror" name="consent_to_treatment" required>
                                <option value="1" {{ $Patientdata->consent_to_treatment == '1' ? 'selected' : '' }}>Yes</option>
                                <option value="0" {{ $Patientdata->consent_to_treatment == '0' ? 'selected' : '' }}>No</option>
                            </select>
                            @error('consent_to_treatment')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="allergies" class="form-label required">Allergies</label>
                            <input type="hidden" name="unique_id" id="unique_id">
                            <input type="text" class="form-control @error('allergies') is-invalid @enderror" name="allergies" value="{{ $Patientdata->allergies }}">
                            @error('allergies')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        
                                              <div class="form-group">
                          <label for="organ_donors" class="form-label">
                              Organ Donors (Optional)
                          </label>
                          <div class="form-check">
                              <input type="checkbox" class="form-check-input @error('organ_donors') is-invalid @enderror" id="organ_donors" name="organ_donors" value="1" {{ $Patientdata->organ_donors ? 'checked' : '' }}>
                              <label class="form-check-label" for="organ_donors">
                                  <i class="mdi mdi-hand-heart menu-icon"></i> I am an organ donor
                              </label>
                          </div>
                          @error('organ_donors')
                          <span class="text-danger">{{ $message }}</span>
                          @enderror
                      </div>

                                    
                        <div class="form-group">
                            <label for="photo" class="form-label required">Photo</label>
                            <input type="file" class="form-control @error('photo') is-invalid @enderror" name="photo" accept="image/*" value="{{ old('photo') }}">
                            @error('photo')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="drivers_license" class="form-label required">Driver's License</label>
                            <input type="file" class="form-control @error('drivers_license') is-invalid @enderror" name="drivers_license" accept="image/*" value="{{ old('drivers_license') }}">
                            @error('drivers_license')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="aadhar_card" class="form-label required">Aadhar Card</label>
                            <input type="file" class="form-control @error('aadhar_card') is-invalid @enderror" name="aadhar_card" accept="image/*" value="{{ old('aadhar_card') }}">
                            @error('aadhar_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="ssn_card" class="form-label required">SSN Card</label>
                            <input type="file" class="form-control @error('ssn_card') is-invalid @enderror" name="ssn_card" accept="image/*" value="{{ old('ssn_card') }}">
                            @error('ssn_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="pan_card" class="form-label required">PAN Card</label>
                            <input type="file" class="form-control @error('pan_card') is-invalid @enderror" name="pan_card" accept="image/*" value="{{ old('pan_card') }}">
                            @error('pan_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                    </div>
                </div>
                
                
                <div class="row">
                    <div class="col-md-12">
                        <label class="form-label required">Assign Roles</label>
                        <div class="row">
                                                     @foreach($roles as $role)
                        <div class="col-md-4">
                            <div class="form-check">
                                <input class="form-check-input" type="checkbox" name="roles[]" value="{{ $role->name }}" 
                                    id="role_{{ $role->id }}" 
                                    {{ $Patientdata->hasRole($role->name) ? 'checked' : '' }}>
                                <label class="form-check-label" for="role_{{ $role->id }}">
                                    {{ ucfirst($role->name) }}
                                    <i class="input-helper"></i>
                                </label>
                            </div>
                        </div>
                    @endforeach
                                                    </div>
                    </div>
                </div>
                
                <button type="submit" class="btn btn-primary me-2">Submit</button>
                <a href="{{ route('admin.patient') }}" class="btn btn-light">Cancel</a>
            </form>
        </div>
    </div>
</div>

@endsection;