@extends('master')

@section('content')
<script type="text/javascript">
	function showContent(checkId, textAreaContent) {
		//alert('Entro: ' + textAreaContent);
        element = document.getElementById(textAreaContent);
        check = document.getElementById(checkId);
        if (check.checked) {
        	$('#none_medication_che').removeAttr("checked");
            element.style.display='block';
        }
        else {
            element.style.display='none';
        }
    }

    function priorWork(){
    	//alert('hola');
    	element = document.getElementById("injury_impairment");
    	textArea = document.getElementById("injury_impairment_text_area");
    	if(element.checked){
    		textArea.style.display='block';
    	}else{
    		textArea.style.display='none';
    	}
    }
	
	function uncheckedNone(other){

		if(other){
		
			$("#none").removeAttr("checked");	
			element = document.getElementById("content_DAH");
	        check = document.getElementById("other_DAH");
	        if (check.checked) {
	            element.style.display='block';
	        }
	        else {
	            element.style.display='none';
	        }

		}else{
			$("#none").removeAttr("checked");	
		}
		
	}

	function BMI(){
		
		var height, weight, bmi, heighttSquared;

		height = document.getElementById("height").value;
		weight = document.getElementById("weight").value;

		height = height * 0.0254;
		weight = weight / 2.2;

		heightSquared = height * height;

		bmi = weight / heightSquared;
		bmi = bmi.toFixed(2);

		document.getElementById("bmi").value = bmi;

	}

	function uncheckedDrugAllergyHistory(){

		$("#penicillin").removeAttr("checked");
		$("#sulfa").removeAttr("checked");
		$("#tetracycline").removeAttr("checked");
		$("#fluoroquinolone").removeAttr("checked");
		$("#other_DAH").removeAttr("checked");

		element = document.getElementById("content_DAH");
		element.style.display='none';

	}
	
	$(document).ready(function(){
		$(document).foundation({
		    abide: {
		        validators: {
		            systolicLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic >= 20 ) && (systolic<= 250));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            diastolicLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic > 0 ) && (systolic<= 140));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            respiratoryRateLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic > 0 ) && (systolic<= 40));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            heartRateLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic > 0 ) && (systolic<= 300));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            temperatureLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic > 0 ) && (systolic<= 140));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            heightLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic >= 48 ) && (systolic<= 86));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            },
		            weightLimits: function(el, required, parent) {
		            	systolic    = el.value;
		               	valid = ((systolic >= 20 ) && (systolic<= 250));
		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            }
		        }
		    }
		});
	});

	function medicationAffectingChE(){
		$("#antidepressants").removeAttr("checked");
		$("#antipsychotics").removeAttr("checked");
		$("#muscle_relaxants").removeAttr("checked");
		$("#antivertigo").removeAttr("checked");
		$("#phenothiazine").removeAttr("checked");
		$("#cardiovascular_medications").removeAttr("checked");
		$("#gi_medications").removeAttr("checked");
		$("#urinary").removeAttr("checked");
		$("#dementia").removeAttr("checked");
		$("#ocular").removeAttr("checked");
		$("#check").removeAttr("checked");
		document.getElementById("content").style.display='none';
		document.getElementById("note_1").style.display='none';
		document.getElementById("note_2").style.display='none';
		document.getElementById("note_3").style.display='none';
		document.getElementById("note_4").style.display='none';
		document.getElementById("note_5").style.display='none';
		document.getElementById("note_6").style.display='none';
		document.getElementById("note_7").style.display='none';
		document.getElementById("note_8").style.display='none';
		document.getElementById("note_9").style.display='none';
		document.getElementById("note_10").style.display='none';	
	}

	function uncheckedNoneMedChE(){
		$('#none_medication_che').removeAttr("checked");
	}
	
	function showStep2(){
		$('#step1').hide();
		$('#step2').show();
	}

	
	function backStep1(){
		$('#step2').hide();
		$('#step1').show();
	}

</script>




   
    <div class="row">
        <div class="large-12 columns">
            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <h4>Initial 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 end ">
                    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 class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <p>This screen is for evaluating baseline ChE levels and health status of workers at the beginning of each spray season. </p>
                </div>
            </div>
        </div>
    </div>

    <div class="row">

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

    			<div class="row">
    		
    				<div class="small-12 medium-3 large-3  columns">
						<hr>
						<h5>Physical Exam Findings</h5>
				        <h6>Vital Signs</h6>

				        <input type="hidden" id="check_in" name="check_in" value="{{{$checkIn}}}" readonly/>

				         <div class="row">
				            <div class="large-12 columns">
					            <label>Systolic BP</label>
					            <input type="number" id="systolic" name="systolic" data-abide-validator="systolicLimits"/>
					            <small class="error" data-error-message>The Systolic value is not in the valid limits</small>
				            </div>
				        </div>

				        <div class="row">
				            <div class="large-12 columns">
					            <label>Diastolic BP</label>
					            <input type="text"  id="diastolic" name="diastolic" data-abide-validator="diastolicLimits"/>
					            <small class="error" data-error-message>The Diastolic value is not in the valid limits</small>
				            </div>
				        </div>

				        <div class="row">
				            <div class="large-12 columns">
					            <label>Respiratory rate</label>
					            <input type="number"  id="respiratory" name="respiratory" placeholder="" data-abide-validator="respiratoryRateLimits"/>
					            <small class="error" data-error-message>The respiratory rate value is not in the valid limits</small>
				            </div>
				        </div>

				        <div class="row">
				        	<div class="row collapse">
						        <label>Heart rate</label>
						        <div class="small-9 columns">
						          <input type="number"  id="heart_rate" name="heart_rate" placeholder="Beats per minute" data-abide-validator="heartRateLimits"/>
						          <small class="error" data-error-message>The heart rate value is not in the valid limits</small>
						        </div>
						        <div class="small-3 columns">
						          <span class="postfix">bpm</span>
						        </div>
						    </div>
				        </div>

				        <div class="row">
				        	<div class="row collapse">
				        		<label>Temperature</label>
					            <div class="small-9 columns">
						            <input type="number" id="temperature" name="temperature" placeholder="Temperature" data-abide-validator="temperatureLimits"/>
						            <small class="error" data-error-message>The respiratory rate value is not in the valid limits</small>
					            </div>
					            <div class="small-3 columns">
						          <span class="postfix">
						          	<select>
										<option value="F">ºF</option>
										<option value="C">ºC</option>
									</select>
						          </span>
							          
						        </div>
				        	</div>
				        </div>

				        <div class="row">
					        <div class="row collapse">
				        		<label>Height Inches</label>
					            <div class="small-9 columns">
						            <input type="number" id="height" name="height" onkeyup="BMI();" placeholder="Height"  data-abide-validator="heightLimits"/>
						            <small class="error" data-error-message>The height value is not in the valid limits</small>
					            </div>
					            <div class="small-3 columns">
						          <span class="postfix">Inches</span>
						        </div>
				        	</div>
				        </div>

				        <div class="row">
					        <div class="row collapse">
				        		<label>Weight</label>
					            <div class="small-9 columns">
						            <input type="number" id="weight" name="weight" onkeyup="BMI();" placeholder="Weight" data-abide-validator="weightLimits"/>
						            <small class="error" data-error-message>The weight value is not in the valid limits</small>
					            </div>
					            <div class="small-3 columns">
						          <span class="postfix">lbs</span>
						        </div>
				        	</div>
				        </div>

				        <div class="row">
					        <div class="row collapse">
				        		<label>BMI</label>
					            <div class="small-9 columns">
						            <input type="number" id="bmi" name="bmi" placeholder="BMI" readonly/>
					            </div>
					            
				        	</div>
				        </div>

				        <div class="row">
				            <div class="large-12 columns">
				            	<p>
				            		<label>
							            <input type="checkbox"  id="injury_impairment" name="injury_impairment" value="1" placeholder="" onclick="priorWork();"/>
							            History of work related injury or impairment (if yes, please specify)
					            	</label>
					            </p>
				            </div>
				            <div class="small-12 medium-12 large-12 end columns" id="injury_impairment_text_area" style="display:none;">
					            <textarea cols="20" rows="4" placeholder="Specify details of the impairment" id="injury_impairment_text" name="injury_impairment_text"></textarea>
				            </div>
				        </div>
					</div>

					<div class="small-12 medium-8 large-8  columns">
						<div class="row">

							<div class="small-12 medium-6 large-6 columns">

								<hr>
					        	<h5>Past Medical History</h5>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="diabetes" name="diabetes" value="1"/>
									            Diabetes
							            	</label>
							            </p>
						            </div>
					            
						        </div>
				        
						        <div class="row">
						        	<div class="large-12 columns">
						        		<p>
						        			<label>
									            <input type="checkbox" placeholder="" id="hypertension" name="hypertension" value="1" />
									            Hypertension
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="irritable" name="irritable" value="1" />
									            Irritable bowel syndrome, inflammatory bowel disorder, or chronic diarrhea
							            	</label>
							            </p>
						            </div>
						            
						        </div>

						        <div class="row">
						        	<div class="large-12 columns">
						        		<p>
						        			<label>
									            <input type="checkbox" placeholder="" id="asthma" name="asthma" value="1"/>
									            Asthma
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
							            	<label>
									            <input type="checkbox" placeholder="" id="possible_prior" name="possible_prior" value="1"/>
									            Possible Prior Episodes of Poisoning Related to Cholinesterase Inhibitors
							            	</label>
							            </p>
						            </div>
						            
						        </div>

						        <div class="row">
						        	<div class="large-12 columns">
						        		<p>
						        			<label>
									            <input type="checkbox" placeholder="" id="acute_exposure" name="acute_exposure" value="1"/>
									            Acute accidental exposure
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="prior_removal" name="prior_removal" value="1"/>
									            Prior removal from handling cholinesterase inhibiting insecticides
							            	</label>
							            </p>
						            </div>
						            
						        </div>

						        <div class="row">
						        	<div class="large-12 columns">
						        		<p>
						        			<label>
									            <input type="checkbox" placeholder="" id="work_related" name="work_related" value="1"/>
									            History of work related illness or injury 
							            	</label>
							            </p>
						            </div>
						        </div>

    						
							</div>

							<div class="small-12 medium-6 large-6  columns">

								<hr>
								<h5>Drug Allergy History</h5>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="penicillin" name="penicillin" value="1" onclick="uncheckedNone();"/>
									            Penicillin
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="sulfa" name="sulfa" value="1" onclick="uncheckedNone();"/>
									            Sulfa
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="tetracycline" name="tetracycline" value="1" onclick="uncheckedNone();"/>
									            Tetracycline
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="fluoroquinolone" name="fluoroquinolone" value="1" onclick="uncheckedNone();"/>
									            Fluoroquinolone
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="other_DAH" name="other_DAH" value="1" onclick="uncheckedNone(true);"/>
									            Other Medication (Please specify)
							            	</label>
							            </p>

							            <div class="row">
							            	<div class="small-12 medium-12 large-12 end columns" id="content_DAH" style="display:none;">
									            <textarea cols="20" rows="4" placeholder="Please specify" id="text_other_medication_DAH" name="text_other_medication_DAH"></textarea>
								            </div>
							            </div>

						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="none" name="none" value="1" onclick='uncheckedDrugAllergyHistory();'/>
									            None
							            	</label>
							            </p>
						            </div>
						        </div>

							</div>

					
						</div>


						<div class="row">

							<div class="small-12 medium-6 large-6  columns">
						    	<hr>
						        <h6>Head and Neck</h6>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="normal_conjunctiva" name="normal_conjunctiva" value="1"/>
									            Normal conjunctiva and EOM
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="pupils_midrange" name="pupils_midrange" value="1"/>
									            Pupils midrange, reactive to light and accomodation
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="neck_normal" name="neck_normal" value="1"/>
									            Neck show normal range of motion, no adenopathy, 
									            thyromegaly or jugular venous distension or carotid bruit
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
							            <textarea rows="4" cols="20" placeholder="Please note abnormal findings" id="abnormal_findings" name="abnormal_findings"></textarea>
						            </div>
						        </div>
				    		</div>

				    		<div class="small-12 medium-6 large-6 columns">
				    	
						    	<hr>
						        <h5>Exercise Capacity</h5>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
							            	<label>
									            <input type="checkbox" placeholder="" id="exercise_normal" name="exercise_normal" value="1"/>
									            Normal
							            	</label>
							            </p>
							            <textarea rows="4" cols="5" placeholder="Please note limitation, if applicable" id="exercise_limitation" name="exercise_limitation"></textarea>
						            </div>
						        </div>

				    		</div>
					
						</div>

					</div>

    			</div>
    	
    			<div class="row">

    				<div class="small-12 medium-12 large-12 columns">

						<div class="row">

							<div class="small-12 medium-6 large-6 columns">
    			
			    				<hr>
						        <h6>Chest</h6>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="no_abnormal_breath_sounds" name="no_abnormal_breath_sounds" value="1"/>
									            No rales, wheezes or abnormal breath sounds
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="normal_cardiac" name="normal_cardiac" value="1"/>
									            Normal cardiac rhythm, no murmurs, or abnormal
									            heart sounds
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
							            <textarea rows="4" cols="20" placeholder="Please note abnormal findings" id="chest_abnormal_findings" name="chest_abnormal_findings"></textarea>
						            </div>
						        </div>

	    				
	    					</div>

		    				<div class="small-12 medium-6 large-6 columns">

			    				<hr>
						        <h6>Abdomen</h6>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="normal_abdominal" name="normal_abdominal" value="1"/>
									            Normal abdominal bowel sounds, no tenderness
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
						            	<p>
						            		<label>
									            <input type="checkbox" placeholder="" id="no_organomegaly" name="no_organomegaly" value="1" />
									            No organomegaly, abdominal masses, or hernias
							            	</label>
							            </p>
						            </div>
						        </div>

						        <div class="row">
						            <div class="large-12 columns">
							            <textarea rows="4" cols="20" placeholder="Please note abnormal findings" id="abdomen_abnormal_findings" name="abdomen_abnormal_findings"></textarea>
						            </div>
						        </div>

    				
    						</div>

	    				</div>



    				</div>
				</div>

			    <div class="row">
			    	<div class="small-12 medium-6 large-6 columns">
			    		<a id="nextButton" onclick="showStep2();" class="button expand">Next</a>
			    	</div>
			    	<div class="small-12 medium-6 large-6 end columns">
			            <a href="{{{ URL::to('patients/'.$patientData->pid) }}}" class="button expand">Cancel</a>
			        </div>
			    </div>

    		
			</div>


	    	<div id="step2" style="display:none;" class="small-12 medium-12 large-12 columns">

	    		<div class="row">
   					<div class="small-12 medium-12 large-12 columns">

				        <h5>
				        	Medication Possibly Affecting Cholinesterase or 
				        	Cholinergic Function
				        </h5>
				        <p>Drug review –possibly should be limited to prospective CME presentation</p>

				        <div class="row">
				        	<div class="small-12 medium-3 large-3 columns">
				        		<p>
				        			<label>
				        				<input type="checkbox" id="none_medication_che" name="none_medication_che" value="1" onclick="medicationAffectingChE();"/>
				        				None
				        			</label>
				        		</p>
				        	</div>
				        </div>

				 
		       			<div class="row">
		            		<div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="antidepressants" name="antidepressants" value="1" onchange="javascript:showContent('antidepressants', 'note_1');"/>
							            Antidepressants (trycyclics [clomipramine
						            	desipramine imipramine amitraptyline <br>
						            	nortriptyline protiptyline ], specific
						            	SSRIs and mixed re-uptake inhibitors<br>
						            	[paroxetine amoxapine])
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_1" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_1" name="text_note_1"></textarea>
						            </div>
					            </div>

		            		</div>

				            <div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="antipsychotics" name="antipsychotics" value="1" onchange="javascript:showContent('antipsychotics', 'note_2');"/>
							            Antipsychotics chlorpromasine clozapine
							            olanzapine thioridazine
					            	</label>
								</p>

								<div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_2" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_2" name="text_note_2"></textarea>
						            </div>
					            </div>


				            </div>

				            <div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="muscle_relaxants" name="muscle_relaxants" value="1" onchange="javascript:showContent('muscle_relaxants', 'note_3');"/>
							            Muscle relaxants cyclobenzaprine dantrolene
							            ophenadrine
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_3" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_3" name="text_note_3"></textarea>
						            </div>
					            </div>

				            </div>

				            <div class="small-12 medium-3 large-3 end columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="antivertigo" name="antivertigo" value="1" onchange="javascript:showContent('antivertigo', 'note_4');"/>
							            ANTIVERTIGO MEDICATIONS meclizine scopolamine
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_4" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_4" name="text_note_4"></textarea>
						            </div>
					            </div>


				            </div>
		            		<hr>
		        		</div>


		        		<div class="row">
		            		<div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="phenothiazine" name="phenothiazine" value="1" onchange="javascript:showContent('phenothiazine', 'note_5');"/>
							            PHENOTHIAZINE ANTIEMETICS prochlorperazine promethazine
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_5" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_5" name="text_note_5"></textarea>
						            </div>
					            </div>

		            		</div>

				            <div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="cardiovascular_medications" name="cardiovascular_medications" value="1" onchange="javascript:showContent('cardiovascular_medications', 'note_6');"/>
							            Cardiovascular medications (furosemide digoxin nifedipine
										disopyramide, beta blockers)
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_6" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_6" name="text_note_6"></textarea>
						            </div>
					            </div>

				            </div>

				            <div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="gi_medications" name="gi_medications" value="1" onchange="javascript:showContent('gi_medications', 'note_7');"/>
							            GI medications - iphenoxilante, atropine, belladonna,
										clidinium, chlordiazepoxide, dicyclomide, hyosciamine
										propantheline 
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_7" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_7" name="text_note_7"></textarea>
						            </div>
					            </div>

				            </div>

				            <div class="small-12 medium-3 large-3 end columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="urinary" name="urinary" value="1" onchange="javascript:showContent('urinary', 'note_8');"/>
							            Urinary anti-spasmodics oxybutynin probantheline
							            solifenacin tolterodine trospium
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_8" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_8" name="text_note_8"></textarea>
						            </div>
					            </div>

				            </div>

		            		<hr>

		        		</div>

		        
		        		<div class="row">
		            		<div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="dementia" name="dementia" value="1" onchange="javascript:showContent('dementia', 'note_9');"/>
							            Dementia (AriCept - donezepil, Exelon - rivastigmine
							            , Razadine - galantamine)
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_9" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_9" name="text_note_9"></textarea>
						            </div>
					            </div>


		            		</div>

				            <div class="small-12 medium-3 large-3 columns">
				            	<p>
				            		<label>
							            <input type="checkbox" placeholder="" id="ocular" name="ocular" value="1" onchange="javascript:showContent('ocular', 'note_10');" />
							            Ocular - neostigmine
					            	</label>
					            </p>

					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="note_10" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="Add Note" id="text_note_10" name="text_note_10"></textarea>
						            </div>
					            </div>

				            </div>

		            		<div class="small-12 medium-3 large-3 columns">
		             			<p>
				             		<label>
							            <input type="checkbox" id="check" name="check" onchange="javascript:showContent('check', 'content');" placeholder="" />
							            Other medication
					            	</label>
			            		</p>
					            
					            <div class="row">
					            	<div class="small-12 medium-12 large-12 end columns" id="content" style="display:none;">
							            <textarea cols="20" rows="4" placeholder="see reference" id="text_other_medication" name="text_other_medication"></textarea>
						            </div>
					            </div>
		            		
		            		</div>
				            
		            		<hr>
		        		</div>

    				</div>
    		
    			</div>


	    		<div class="row">
	    			<div class="small-12 medium-4 large-4 columns">
			    		<a id="backButton" onclick="backStep1();" class="button expand">Back</a>
			    	</div>
			        <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