@extends('master')

@section('content')
<script type="text/javascript">
	
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		$(document).foundation({
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		        validators: {
		            heightLimits: function(el, required, parent) {
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		               	parent.closest( 'small.error').css({display:'block'});
			  			return valid;
		            }
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		    }
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</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">
                    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 . '/initial-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>
						<h5>General Health</h5>
				        <input type="hidden" id="check_in" name="check_in" value="{{{$checkIn}}}" readonly/>

				        <div class="row">
					        <div class="large-6 columns">
					        	<div class="row">
					        		<label>Height Inches</label>
						            <div class="small-9 columns">
							            <input type="number" id="height" name="height" 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="large-6 columns">
				        		<div class="row">
				        			<label>Weight</label>
					            	<div class="small-9 columns">
						            	<input type="number" id="weight" name="weight" 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>
					</div>
    			</div>

    			<div class="row">
    				<div class="small-12 medium-6 large-6  columns">
						<hr>
						<h5>Health History</h5>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="good_health" name="good_health" value="1"/> Good general health (historia de buena salud)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label>Exercise Capacity (Capacidad de hacer trabajo pesado)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="excercise_normal" name="excercise_normal" value="1"/> Normal</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label>Ability to use respirator in the past (capacidad de utilizar respirador)</label>
					        </div>
				        </div>
				        <div class="row">
				            <div class="large-2 columns">
				            	<p>
				            		<label><input type="checkbox" id="respirator" name="respirator" value="1"/> Yes (Si)</label>
					            </p>
				            </div>
				            <div class="large-2 end columns">
				            	<p>
				            		<label><input type="checkbox" id="respirator" name="respirator" value="0" /> No</label>
					            </p>
				            </div>
				        </div>   
				        <hr>
						<h5>Drug Allergy History (Historia de alergia a drogas)</h5> 
						<div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="allergy_penicillin" name="allergy_penicillin" value="1"/> Penicillin (penicilina)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="allergy_sulfa" name="allergy_sulfa" value="1"/> Sulfa (Sulfamida)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="allergy_tetracycline" name="allergy_tetracycline" value="1"/> Tetracycline (tetraciclina)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="allergy_fluoroquinolone" name="allergy_fluoroquinolone" value="1"/> Fluoroquinolone (las fluoroquinolonas)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="allergy_other" name="allergy_other" value="1"/> Other Medication (Please specify) [Otra medicina (especifíquese)] </label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label>Specify:</label>
						        <input type="textarea" id="allergy_other_text" name="allergy_other_text" value="1"/>
					        </div>
				        </div>
					</div>
					<div class="small-12 medium-6 large-6  columns">
				        <hr>
						<h5>Past Medical History (Historia de problemas medicos)</h5>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_diabetes" name="history_diabetes" value="1"/> Diabetes</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_hypertension" name="history_hypertension" value="1"/> Hypertension (Alta presion de sangre)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_abdominal" name="history_abdominal" value="1"/> Abdominal problems e.g. Irritable bowel syndrome, inflammatory bowel disorder or chronic diarrhea ( Problemas abdominales: por ejemplo, sindrome de intestino irritable, desorden/trastorno de intestino inflamatorio o diarrea cronica</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_asthma" name="history_asthma" value="1"/> Asthma (Asma)</label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_poisoning" name="history_poisoning" value="1"/> Possible prior episodes of poisoning related to Cholinesterase inhibitors (Posibles episodios previos de envenenamiento relacionado con inhibidores de Colinesterasa) </label>
					        </div>
				        </div>
				        <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_exposure" name="history_exposure" value="1"/> Acute accidental exposure. For example, from a broken hose line (Exposición aguda accidental, por ejemplo, por línea de manguera rota)</label>
					        </div>
				        </div>
				         <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_removal" name="history_removal" value="1"/> Prior removal from handling cholinesterase inhibiting insecticides (limitación de trabajo en el pasado debido a manejo de inhibidores de colinesterasa )</label>
					        </div>
				        </div>
				         <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_work" name="history_work" value="1"/> History of work related illness or injury (Historia de enfermedades o lesiones relacionadas al trabajo)</label>
					        </div>
				        </div>
				         <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_anxiety" name="history_anxiety" value="1"/> Anxiety – depression  (ansiedad o depresión)</label>
					        </div>
				        </div>
				         <div class="row">
					        <div class="small-9 columns">
						        <label><input type="checkbox" id="history_fainting" name="history_fainting" value="1"/> Fainting spell or other problem with blood draw (Desmayo, ansiesdad u otro problema cuando se le saca la sangre)</label>
					        </div>
				        </div>

				        
					</div>
    			</div>
    	
    			<div class="row">
    				<div class="small-12 medium-12 large-12  columns">
				        <hr>
						<h5>Symptom review (Revision de síntomas)</h5>
						<div class="row">
							<div class="small-12 medium-6 large-6 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Neurology, general symptoms  (Neurología, síntomas generals) 
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-12 columns">
						            	Fatigue (Cansancio) 
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="fatigue" name="fatigue" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="fatigue" name="fatigue" value="0" />No</label>
							            </p>
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-12 columns">
						            	Headache (Dolor de cabeza) 
						            </div>
						        </div>
						       <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="headache" name="headache" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="headache" name="headache" value="0" />No</label>
							            </p>
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-12 columns">
						            	Nausea (Nausea o Asco) 
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="nausea" name="nausea" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="nausea" name="nausea" value="0" />No</label>
							            </p>
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-12 columns">
						            	Dizziness (Mareos) 
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="dizziness" name="dizziness" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="dizziness" name="dizziness" value="0" />No</label>
							            </p>
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-12 columns">
						            	Abnormal Sweating (sudor excesivo) 
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="sweating" name="sweating" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="sweating" name="sweating" value="0" />No</label>
							            </p>
						            </div>
						        </div>
						    </div>
						    <div class="small-12 medium-6 large-6 columns">
						        <div class="row">
									<div class="small-12 medium-12 large-12 columns">
								        <h6>Abdomen</h6>
									</div>
								</div>
								<div class="row">
				    				<div class="small-12 medium-12 large-12 columns">
								        <div class="row">
								            <div class="large-12 columns">
								            	Diarrhea (diarrea)
								            </div>
								        </div>
								        <div class="row">
								            <div class="large-2 columns">
								            	<p>
								            		<label><input type="checkbox" id="diarrhea" name="diarrhea" value="1"/>Yes (Si)</label>
									            </p>
								            </div>
								            <div class="large-2 end columns">
								            	<p>
								            		<label><input type="checkbox" id="diarrhea" name="diarrhea" value="0" />No</label>
									            </p>
								            </div>
								        </div>				
		    						</div>
				    				<div class="small-12 medium-12 large-12 columns">
								        <div class="row">
								            <div class="large-12 columns">
								            	Abdominal pain (Dolor del abdomen)
								            </div>
								        </div>
								        <div class="row">
								            <div class="large-2 columns">
								            	<p>
								            		<label><input type="checkbox" id="abdominal" name="abdominal" value="1"/>Yes (Si)</label>
									            </p>
								            </div>
								            <div class="large-2 end columns">
								            	<p>
								            		<label><input type="checkbox" id="abdominal" name="abdominal" value="0" />No</label>
									            </p>
								            </div>
								        </div> 				
		    						</div>
			    				</div>
			    				<div class="row">
				    				<div class="small-12 medium-12 large-12 columns">
								        <div class="row">
								            <div class="large-12 columns">
								            	Hernia
								            </div>
								        </div>
								        <div class="row">
								            <div class="large-2 columns">
								            	<p>
								            		<label><input type="checkbox" id="hernia" name="hernia" value="1"/>Yes (Si)</label>
									            </p>
								            </div>
								            <div class="large-2 end columns">
								            	<p>
								            		<label><input type="checkbox" id="hernia" name="hernia" value="0" />No</label>
									            </p>
								            </div>
								        </div>			
		    						</div>
			    				</div>   				
    						</div>
						</div>
					</div>
				</div>
				<div class="row">
    				<div class="small-12 medium-6 large-6  columns">
				        <hr>
						Chest
						<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Wheezing (Silbidos al respirar/resollar)
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="wheezing" name="wheezing" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="wheezing" name="wheezing" value="0" />No</label>
							            </p>
						            </div>
						        </div>				
    						</div>
	    				</div>  
	    				<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Cough (tos)
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="cough" name="cough" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="cough" name="cough" value="0" />No</label>
							            </p>
						            </div>
						        </div>			
    						</div>
	    				</div>   	
	    				<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Chest pain (dolor de pecho)
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="chest" name="chest" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="chest" name="chest" value="0" />No</label>
							            </p>
						            </div>
						        </div>			
    						</div>
	    				</div>   	 			
	    				<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Irregular heart rate (Palpitaciones)
						            </div>
						        </div>
						       <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="heart" name="heart" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="heart" name="heart" value="0" />No</label>
							            </p>
						            </div>
						        </div>		
    						</div>
	    				</div>   	
					</div>
					<div class="small-12 medium-12 large-6  columns">
				        <hr>
						Extremities (extremidades)
						<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Arthritis (Artritis)
						            </div>
						        </div>
						       <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="arthritis" name="arthritis" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="arthritis" name="arthritis" value="0" />No</label>
							            </p>
						            </div>
						        </div>
    						</div>
	    				</div>  
	    				<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	History of joint pain (dolor en las coyunturas)
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="joint" name="joint" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="joint" name="joint" value="0" />No</label>
							            </p>
						            </div>
						        </div>    				
    						</div>
	    				</div>   	 			
	    				<div class="row">
		    				<div class="small-12 medium-12 large-12 columns">
						        <div class="row">
						            <div class="large-12 columns">
						            	Swelling (Hinchazon - por ejemplo en las piernas)
						            </div>
						        </div>
						        <div class="row">
						            <div class="large-2 columns">
						            	<p>
						            		<label><input type="checkbox" id="swelling" name="swelling" value="1"/>Yes (Si)</label>
							            </p>
						            </div>
						            <div class="large-2 end columns">
						            	<p>
						            		<label><input type="checkbox" id="swelling" name="swelling" value="0" />No</label>
							            </p>
						            </div>
						        </div>    				
    						</div>
	    				</div>   	
					</div>
				</div>
				<div class="row">
    				<div class="small-12 medium-12 large-12 columns">
    					<hr>
				        <div class="row">
				            <div class="large-12 columns">
				            	Trouble with circulation  (Dificultad de la circulacion)
				            </div>
				        </div>
				        <div class="row">
				            <div class="large-2 columns">
				            	<p>
				            		<label><input type="checkbox" id="circulation" name="circulation" value="1"/>Yes (Si)</label>
					            </p>
				            </div>
				            <div class="large-2 end columns">
				            	<p>
				            		<label><input type="checkbox" id="circulation" name="circulation" value="0" />No</label>
					            </p>
				            </div>
				        </div>    				
					</div>
				</div>  
				<div class="row">
    				<div class="small-12 medium-6 large-12 columns">
				        <div class="row">
				            <div class="large-12 columns">
				            	Back problems  (Dolor o otra problema en la espalda)
				            </div>
				        </div>
				        <div class="row">
				            <div class="large-2 columns">
				            	<p>
				            		<label><input type="checkbox" id="back" name="back" value="1"/>Yes (Si)</label>
					            </p>
				            </div>
				            <div class="large-2 end columns">
				            	<p>
				            		<label><input type="checkbox" id="back" name="back" value="0" />No</label>
					            </p>
				            </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