@extends('layouts.app')

@section('content')
<div class="container">
    <div class="row justify-content-center">
        <div class="col-md-12">
            <div class="card">
                <div class="card-header">{{ __('Edit Patient') }}</div>

                <div class="card-body">
                    <form method="POST" action="{{ route('patients.update', $patient->patient_id) }}" enctype="multipart/form-data">
                        @csrf
                        @method('PUT')

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="first_name" class="form-label">First Name</label>
                                <input type="text" class="form-control" name="first_name" value="{{ $patient->first_name }}" required>
                            </div>
                            <div class="col-md-6">
                                <label for="last_name" class="form-label">Last Name</label>
                                <input type="text" class="form-control" name="last_name" value="{{ $patient->last_name }}" required>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="middle_name" class="form-label">Middle Name</label>
                                <input type="text" class="form-control" name="middle_name" value="{{ $patient->middle_name }}">
                            </div>
                            <div class="col-md-6">
                                <label for="date_of_birth" class="form-label">Date of Birth</label>
                                <input type="date" class="form-control" name="date_of_birth" value="{{ $patient->date_of_birth }}" required>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="sex" class="form-label">Gender</label>
                                <select class="form-select" name="sex" required>
                                    <option value="">Select Gender</option>
                                    <option value="Male" {{ $patient->sex == 'Male' ? 'selected' : '' }}>Male</option>
                                    <option value="Female" {{ $patient->sex == 'Female' ? 'selected' : '' }}>Female</option>
                                    <option value="Other" {{ $patient->sex == 'Other' ? 'selected' : '' }}>Other</option>
                                </select>
                            </div>
                            <div class="col-md-6">
                                <label for="address" class="form-label">Address</label>
                                <input type="text" class="form-control" name="address" value="{{ $patient->address }}" required>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="patient_phone_num_country_code" class="form-label">Phone Number (Country Code)</label>
                                <input type="text" class="form-control" name="patient_phone_num_country_code" value="{{ $patient->patient_phone_num_country_code }}">
                            </div>
                            <div class="col-md-6">
                                <label for="patient_phone_number" class="form-label">Phone Number</label>
                                <input type="text" class="form-control" name="patient_phone_number" value="{{ $patient->patient_phone_number }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="patient_er_country_code" class="form-label">Emergency Phone Number (Country Code)</label>
                                <input type="text" class="form-control" name="patient_er_country_code" value="{{ $patient->patient_er_country_code }}">
                            </div>
                            <div class="col-md-6">
                                <label for="patient_er_phone_number" class="form-label">Emergency Phone Number</label>
                                <input type="text" class="form-control" name="patient_er_phone_number" value="{{ $patient->patient_er_phone_number }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="aadhar_card_num" class="form-label">Aadhar Card Number</label>
                                <input type="text" class="form-control" name="aadhar_card_num" maxlength="20" value="{{ $patient->aadhar_card_num }}">
                            </div>
                            <div class="col-md-6">
                                <label for="pan_card_num" class="form-label">PAN Card Number</label>
                                <input type="text" class="form-control" name="pan_card_num" maxlength="20" value="{{ $patient->pan_card_num }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="ssn_card_num" class="form-label">SSN Card Number</label>
                                <input type="text" class="form-control" name="ssn_card_num" maxlength="20" value="{{ $patient->ssn_card_num }}">
                            </div>
                            <div class="col-md-6">
                                <label for="cibil_score" class="form-label">CIBIL Score</label>
                                <input type="number" class="form-control" name="cibil_score" min="0" max="999" value="{{ $patient->cibil_score }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="profession" class="form-label">Profession</label>
                                <input type="text" class="form-control" name="profession" value="{{ $patient->profession }}">
                            </div>
                            <div class="col-md-6">
                                <label for="employment_status" class="form-label">Employment Status</label>
                                <input type="text" class="form-control" name="employment_status" value="{{ $patient->employment_status }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="marital_status" class="form-label">Marital Status</label>
                                <input type="text" class="form-control" name="marital_status" value="{{ $patient->marital_status }}">
                            </div>
                            <div class="col-md-6">
                                <label for="father_name" class="form-label">Father's Name</label>
                                <input type="text" class="form-control" name="father_name" value="{{ $patient->father_name }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="mother_name" class="form-label">Mother's Name</label>
                                <input type="text" class="form-control" name="mother_name" value="{{ $patient->mother_name }}">
                            </div>
                            <div class="col-md-6">
                                <label for="male_siblings" class="form-label">Number of Male Siblings</label>
                                <input type="number" class="form-control" name="male_siblings" min="0" value="{{ $patient->male_siblings }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="female_siblings" class="form-label">Number of Female Siblings</label>
                                <input type="number" class="form-control" name="female_siblings" min="0" value="{{ $patient->female_siblings }}">
                            </div>
                            <div class="col-md-6">
                                <label for="consent_to_contact" class="form-label">Consent to Contact</label>
                                <select class="form-select" name="consent_to_contact" required>
                                    <option value="1" {{ $patient->consent_to_contact == 1 ? 'selected' : '' }}>Yes</option>
                                    <option value="0" {{ $patient->consent_to_contact == 0 ? 'selected' : '' }}>No</option>
                                </select>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="medical_billing_address" class="form-label">Medical Billing Address</label>
                                <input type="text" class="form-control" name="medical_billing_address" value="{{ $patient->medical_billing_address }}">
                            </div>
                            <div class="col-md-6">
                                <label for="current_medications" class="form-label">Current Medications</label>
                                <input type="text" class="form-control" name="current_medications" value="{{ $patient->current_medications }}">
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="previous_health_history" class="form-label">Previous Health History</label>
                                <input type="text" class="form-control" name="previous_health_history" value="{{ $patient->previous_health_history }}">
                            </div>
                            <div class="col-md-6">
                                <label for="consent_to_treatment" class="form-label">Consent to Treatment</label>
                                <select class="form-select" name="consent_to_treatment" required>
                                    <option value="1" {{ $patient->consent_to_treatment == 1 ? 'selected' : '' }}>Yes</option>
                                    <option value="0" {{ $patient->consent_to_treatment == 0 ? 'selected' : '' }}>No</option>
                                </select>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="allergies" class="form-label">Allergies</label>
                                <input type="text" class="form-control" name="allergies" value="{{ $patient->allergies }}">
                            </div>
                            <div class="col-md-6">
                                <label for="photo" class="form-label">Photo</label>
                                <input type="file" class="form-control" name="photo">
                                @if ($patient->photo)
                                    <img src="{{ asset('storage/'.$patient->photo) }}" alt="Patient Photo" width="100">
                                @endif
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="drivers_license" class="form-label">Driver's License</label>
                                <input type="file" class="form-control" name="drivers_license">
                                @if ($patient->drivers_license)
                                    <a href="{{ asset('storage/'.$patient->drivers_license) }}" target="_blank">View</a>
                                @endif
                            </div>
                            <div class="col-md-6">
                                <label for="aadhar_card" class="form-label">Aadhar Card</label>
                                <input type="file" class="form-control" name="aadhar_card">
                                @if ($patient->aadhar_card)
                                    <a href="{{ asset('storage/'.$patient->aadhar_card) }}" target="_blank">View</a>
                                @endif
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="ssn_card" class="form-label">SSN Card</label>
                                <input type="file" class="form-control" name="ssn_card">
                                @if ($patient->ssn_card)
                                    <a href="{{ asset('storage/'.$patient->ssn_card) }}" target="_blank">View</a>
                                @endif
                            </div>
                            <div class="col-md-6">
                                <label for="pan_card" class="form-label">PAN Card</label>
                                <input type="file" class="form-control" name="pan_card">
                                @if ($patient->pan_card)
                                    <a href="{{ asset('storage/'.$patient->pan_card) }}" target="_blank">View</a>
                                @endif
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-6">
                                <label for="unique_id" class="form-label">Unique ID</label>
                                <input type="text" class="form-control" name="unique_id" value="{{ $patient->unique_id }}" required>
                            </div>
                        </div>

                        <div class="row mb-3">
                            <div class="col-md-12">
                                <button type="submit" class="btn btn-primary">Update Patient</button>
                                <a href="{{ route('patients.index') }}" class="btn btn-secondary">Cancel</a>
                            </div>
                        </div>

                    </form>
                </div>
            </div>
        </div>
    </div>
</div>
@endsection