@extends('master')

<link href="{{{URL::to("//netdna.bootstrapcdn.com/font-awesome/4.0.3/css/font-awesome.css")}}}" rel="stylesheet">
<link rel="stylesheet" href="{{{ URL::to('lib/foundation/css/foundation-datepicker.css') }}}" />

@section('content')

<script>

	function customLetter(){
    	element = document.getElementById("custom_letter");
    	textArea = document.getElementById("custom_letter_text_area");
    	if(element.checked){
    		textArea.style.display='block';
    	}else{
    		textArea.style.display='none';
    	}
    }

</script>

	<div class="row">
        <div class="large-12 columns">
            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <h4>Patient And Employeer Notification Center</h4>
                </div>
            </div>

            <div class="row">
                <div class="small-6 medium-6 large-6 columns">
                    <h5>{{{ $patientData->fname . " " . $patientData->lname }}}</h5>
                </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> </p>
                </div>
            </div>
        </div>
    </div>

<form action="{{{ URL::to('patients/'.$patientData->pid.'/notification/employer-letter') }}}" method="post" data-abide>

	<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>
			        <h5>After Baseline Testing</h5>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="noRestrictions_ABT" name="restrictions_ABT" value="no" />
						            Release to work with no restictions, pending results
						            of baseline test
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="withRestrictions_ABT" name="restrictions_ABT" value="with" />
						            Relase to work with restriction, pending results of
						            baseline
				            	</label>
				            </p>
			            </div>
			        </div>

			         <div class="row">
			            <div class="large-12 columns">
				            <textarea rows="4" cols="20" id="textRestrictions_ABT" name="textRestrictions_ABT" placeholder="Please specify work activity restrictions"></textarea>
			            </div>
			        </div>
					
				</div>

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

					<hr>
			        <h5>Follow-up Testing</h5>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="oneMonth_FUT" name="date_FUT" value="one_month"/>
						            Return in 1 month for serum (BuChE) and red blod cel (AChE)
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			           <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="otherDate_FUT" name="date_FUT" value="other"/>
						            Other date for serum (BuChE) and red blod cel (AChE)
				            	</label>
				            </p>
			            </div> 			            
			        </div>

			        <div class="row">

			            <!--<div class="large-12 columns">
				            <textarea rows="4" cols="20" id="textDate_FUT" name="textDate_FUT" placeholder="Please specify test date or approximate interval"></textarea>
			            </div>-->

			            <!-- Date for follow-up-->

			            <div class="small-12  columns">
			                <div class="row collapse date" id="dp3" data-date-format="yyyy-mm-dd">
			                  	<label>Please specify test date or approximate interval</label>
			                  	<div class="small-9 columns">
			                    	<input type="text" id="textDate_FUT" name="textDate_FUT" placeholder="" pattern="date" readonly/>
			                    	<small class="error" data-error-message>Date format: yyyy-mm-dd.</small>
			                  	</div>
			                  	<div class="small-3 columns">
			                    	<span class="postfix"><i class="fa fa-calendar"></i></span>
			                  	</div>
			                </div>
			            </div> 

			        </div> 

				</div>
				
			</div>

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


					<hr>
					<h5>After Follow-up Testing and Test Review</h5>

			         <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="noRestrictions_AFUTTR" name="restrictions_AFUTTR" value="no"/>
						            Release to work with no restictions, pending results
						            of baseline test
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="withRestrictions_AFUTTR" name="restrictions_AFUTTR" value="with"/>
						            Relase to work with restriction, pending results of
						            baseline
				            	</label>
				            </p>
			            </div>
			        </div>

			         <div class="row">
			            <div class="large-12 columns">
				            <textarea rows="4" cols="20" id="textRestrictions_AFUTTR" name="textRestrictions_AFUTTR" placeholder="Please specify work activity restrictions"></textarea>
			            </div>
			        </div>


					
				</div>

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


			        <hr>
			        <h5>Additional Follow-up Testing</h5>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="oneMonth_AFUT" name="date_AFUT" value="one_month"/>
						            Return in 1 month for serum (BuChE) and red blod cel (AChE)
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="otherDate_AFUT" name="date_AFUT" value="other"/>
						            Other date for serum (BuChE) and red blod cel (AChE)
				            	</label>
				            </p>
			            </div>
			        </div>

			        <!-- <div class="row">
			            <div class="large-12 columns">
				            <textarea rows="4" cols="20" id="textDate_AFUT" name="textDate_AFUT" placeholder="Please specify test date or approximate interval"></textarea>
			            </div>
			        </div> -->

			        <div class="small-12  columns">
		                <div class="row collapse date" id="dp3" data-date-format="yyyy-mm-dd">
		                  	<label>Please specify test date or approximate interval</label>
		                  	<div class="small-9 columns">
		                    	<input type="text" id="textDate_AFUT" name="textDate_AFUT" placeholder="" pattern="date" readonly/>
		                    	<small class="error" data-error-message>Date format: yyyy-mm-dd.</small>
		                  	</div>
		                  	<div class="small-3 columns">
		                    	<span class="postfix"><i class="fa fa-calendar"></i></span>
		                  	</div>
		                </div>
		            </div> 

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

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

			        <h5>Activity Restrictions</h5>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="noRestrictions_AR" name="restrictions_AR" value="no"/>
						            Release to work with no restictions, but recommend investigation of work practices
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			            <div class="large-12 columns">
			            	<p>
			            		<label>
						            <input type="radio" placeholder="" id="noHandling_AR" name="restrictions_AR" value="no_handling"/>
						            No handling of ChE inhibiting insecticides - pending results of follow-up tests
				            	</label>
				            </p>
			            </div>
			        </div>

			        <div class="row">
			            <div class="large-12 columns">
				            <textarea rows="4" cols="20" id="additionalRestrictions_AR" name="additionalRestrictions_AR" placeholder="Please specify additional work activity restrictions "></textarea>
			            </div>
			        </div>
					
				</div>

				<div class="small-12 medium-6 large-6 columns">
					<h5>Custom Letter</h5>

					<div class="row">
				            <div class="large-12 columns">
				            	<p>
				            		<label>
							            <input type="checkbox"  id="custom_letter" name="custom_letter" value="1" placeholder="" onclick="customLetter();"/>
							            Want a custom letter for notification?
					            	</label>
					            </p>
				            </div>
				            <div class="small-12 medium-12 large-12 end columns" id="custom_letter_text_area" style="display:none;">
					            <textarea cols="20" rows="4" placeholder="Write custom letter for notification" id="custom_letter_text" name="custom_letter_text"></textarea>
				            </div>
				        </div>


				</div>
			</div>

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

				        <div class="small-12 medium-3 large-3 end columns">
				            <button type="submit" name="preview" value='preview' target="_blank" class="expand">Preview</button>
				        </div>

				        <div class="small-12 medium-3 large-3 columns">
				            <!-- <a href="{{{ URL::to('patients/'.$patientData->pid.'/notification/employer-letter') }}}" class="button">Send</a> -->
				            <button class="expand">Send</button>
				        </div>
				        <div class="small-12 medium-3 large-3 end columns">
				            <button type="submit" name="download" value='download' target="_blank" class="expand">Download</button>
				        </div>
				        <div class="small-12 medium-3 large-3 end columns">
				            <a href="{{{ URL::to('patients/'.$patientData->pid) }}}" class="button expand">Cancel</a>
				        </div>

				    </div>
				</div>				
			</div>


			


		</div>
	</div>


</form>		

	<script src="//ajax.googleapis.com/ajax/libs/jquery/1.10.2/jquery.min.js"></script>
    <script src="{{{URL::to('lib/foundation/js/foundation-datepicker.js')}}}"></script>


    <script>

      (function($) {
         
        $('.date').fdatepicker();

        $("#otherDate_FUT").click(function(){  
        	$("#textDate_FUT").prop('required',true);
	    });

	    $("#oneMonth_FUT").click(function(){   
	    	$("#textDate_FUT").prop('required',false);       
	    });

	    $("#otherDate_AFUT").click(function(){  
        	$("#textDate_AFUT").prop('required',true);
	    });

	    $("#oneMonth_AFUT").click(function(){   
	    	$("#textDate_AFUT").prop('required',false);       
	    });
                
         
      })(jQuery);
    </script>
    
@stop