@extends('master')

@section('content')
   
    <div class="row">
        <div class="large-12 columns">
            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <h4>Follow Up Questionnaire</h4>
                </div>
            </div>

            <div class="row">
                <div class="small-6 medium-6 large-6 columns">
                    <h5>{{{ $patientData->fname . " " . $patientData->lname }}}</h5>
                </div>
                <div class="small-6 medium-6 large-6 columns">
                    Date Of Birth: {{{ $patientData->DOB }}}
                </div>
            </div>

            <div class="row">
                <div class="small-4 medium-4 large-4 columns">
                    <h5>Employer: {{{ $employer->name }}}</h5>
                </div>
            </div>
        </div>
    </div>

    <div class="row">

    	<form action="{{{ URL::to('patients/' . $patientData->pid . '/follow-questionnaire') }}}" method="post" data-abide>
	
			<div id="step1" class="small-12 medium-12 large-12 columns">

    			<div class="row">
    				<div class="small-12 medium-12 large-12  columns">
						<hr>
						<h4>Review of Symptoms Possibly Related to ChE Inhibition</h4>
						<h5>Positive answers suggest possible illness related to ChE inhibitor that may require laboratory evaluation</h5>
				        <input type="hidden" id="check_in" name="check_in" value="{{{$checkIn}}}" readonly/>

				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="headache" name="headache" value="1" />Headache  (dolor de cabeza)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="trouble" name="trouble" value="1" />Trouble concentrating  (dificultad de enfocar la atencion)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="blurry" name="blurry" value="1" />Blurry vision  (vista borrosa) </label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="wheezing" name="wheezing" value="1" />Wheezing  (resuello o silbidos del pecho durante respiracion)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="salivation" name="salivation" value="1" />Excessive Salivation (salivación  excesiva)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="abdominal" name="abdominal" value="1" />Abdominal pain (dolor de abdomen)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="diarrhea" name="diarrhea" value="1" />Diarrhea (diarrea) </label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="muscle" name="muscle" value="1" />Muscle twitching ( contracciones musculares involuntarias.)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="loss" name="loss" value="1" />Loss of control of urine or excessive urination  (Pérdida de control de orina o urinación excesiva)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="sweating" name="sweating" value="1" />Excessive sweating (sudor excesivo  o sudoración exesiva)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="exposures" name="exposures" value="1" />Exposures (record any unusual exposure events – broken hose lines, spills, etc)</label>
					        </div>
				        </div>
				        <div class="row">
				        	<div class="large-12 columns">
				        		<label>Las exposiciones (registran cualquier acontecimiento de exposición insólito - líneas de manguera rotas, trozos, etc.) </label>
				        		<textarea id="exposures_text" name="exposures_text" ></textarea>
				        	</div>
				        </div>
					</div>
    			</div>

    			<div class="row">
    				<div class="small-12 medium-12 large-12 columns">
						<hr>
						<h5>Illnesses</h5>
				        <div class="row">
					        <div class="large-12 columns">
						        <label><input type="checkbox" placeholder="" id="illness" name="illness" value="1" />History of any recent illness, whether related to work or not (Enfermedades Historia de cualquier enfermedad reciente, si relacionado trabajar o no)</label>
					        </div>
				        </div>
				        <div class="row">
				        	<div class="large-12 columns">
				        		<label>Illnesses</label>
				        		<textarea id="illness_text" name="illness_text" ></textarea>
				        	</div>
				        </div>
					</div>
    			</div>
    	
    			
			    <div class="row">
			    	<div class="small-12 medium-4 large-4 columns">
			            <button class="expand">Save</button>
			        </div>
			        <div class="small-12 medium-4 large-4 end columns">
			            <a href="{{{ URL::to('patients/'.$patientData->pid) }}}" class="button expand">Cancel</a>
			        </div>
			    </div>
			</div>
	    	
	    

	    </form> 
      	
    </div>

    
@stop