@extends('master')

@section('content')
<script type="text/javascript">
  $(document).ready(function(){
    $(document).foundation();
  });
  function showContent(){

    $('#checkAddress').change(function(){
     if(this.checked){

      $('#address').hide();
      $('#proxyAddress').show();

      document.getElementById("address1").value = 'N/A';
      document.getElementById("address2").value = 'N/A';
      document.getElementById("city").value = 'N/A';
      document.getElementById("state").value = 'N/A';
      document.getElementById("postal_code").value = '00000';

    }else{

      $('#address').show();
      $('#proxyAddress').hide();

      document.getElementById("address1").value = '';
      document.getElementById("address2").value = '';
      document.getElementById("city").value = '';
      document.getElementById("state").value = '';
      document.getElementById("postal_code").value = '';

    }
  });
  }

  function proxyAddress(){
    $('#checkProxy').change(function(){

      if(this.checked){
        $('#proxy').show();
        document.getElementById("address1").value = '';
        document.getElementById("address2").value = '';
        document.getElementById("city").value = '';
        document.getElementById("state").value = '';
        document.getElementById("postal_code").value = '';
      //$('#address').show();
    }else{
      $('#proxy').hide();
      document.getElementById("address1").value = 'N/A';
      document.getElementById("address2").value = 'N/A';
      document.getElementById("city").value = 'N/A';
      document.getElementById("state").value = 'N/A';
      document.getElementById("postal_code").value = '00000';
    }

  });

  }
</script>

<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') }}}" />

<div class="row">

  @if(isset($error)) 
  <div class="small-12 large-12 columns">
    <div data-alert class="alert-box alert">
      {{{$error}}}
      <a href="#" class="close">&times;</a> 
    </div>			
  </div>
  @endif  

  <div class="large-12 columns">
    <div class="row">
      <div class="small-12 medium-12 large-12 columns">
        <h2>Patient Information</h2>
      </div>
    </div>

    <div class="row">
      <div class="small-12 medium-12 large-12 columns">
        <p>This screen is for editing patient demographic information. </p>
      </div>
    </div>
  </div>
</div>

<div class="row">

 <!-- <form action="{{{ URL::to('patients') }}}" method="PATCH" data-abide>  -->

   {{ Form::model($patientData, array('route' => array('patients.update', $patientData->pid), 'method' => 'PUT', 'data-abide')) }}

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

     <!--  <form> -->

      <div class="row">
        <div class="small-12 medium-12 large-10 columns">
          <label>First Name</label>
          <input type="text" id="first_name" name="first_name" placeholder="" required pattern="[a-zA-Z]+" value="{{{ $patientData->fname }}}"/>
          <small class="error" data-error-message>First Name is required and must be a string.</small>
        </div>
        <div class="small-4 medium-2 large-2 columns">
          <label>Middle Name</label>
          <input type="text" id="middle_name" name="middle_name" placeholder="" pattern="[a-zA-Z]+" value="{{{ $patientData->mname }}}"/>
          <small class="error" data-error-message>Must be a string.</small>
        </div>

      </div>

      <div class="row">
        <div class="small-12 medium-10 large-10 columns">
          <label>Last Name</label>
          <input type="text" id="last_name" name="last_name" placeholder="" required pattern="[a-zA-Z]+" value="{{{ $patientData->lname }}}"/>
          <small class="error" data-error-message>Last Name is required and must be a string.</small>
        </div>
      </div>


      <div class="row">
        <div class="small-12 medium-6 large-6 columns">
          <div class="row collapse date" id="dp3" data-date-format="yyyy-mm-dd">
            <label>DOB</label>
            <div class="small-9 columns">
              <input type="text" id="DOB" name="DOB" pattern="date" value="{{{ $patientData->DOB }}}" />
              <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 class="row">
        <div class="small-12 medium-6 large-6 columns">
          <label>Sex ( {{{$patientData->sex}}} )</label>
          <select id="sex" name="sex">
            <option value="Male" >Male</option>
            <option value="Female" >Female</option>                  
          </select>
        </div>
      </div>
      <div class="row">
        <div class="small-12 medium-4 large-5 columns">
          <label>Email</label>
          <input type="email" id="email" name="email" required placeholder="" value="{{{ $patientData->email }}}" />
          <small class="error" data-error-message>Invalid email format.</small>

        </div>
        <div class="small-12 medium-4 large-5 end columns">
          <label>Phone (Home)</label>
          <input type="text" id="phone_home" name="phone_home" placeholder="" value="{{{ $patientData->phone_home }}}" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
          <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
        </div>
      </div>

      <div class="row">
       <div class="small-12 medium-4 large-5 columns">
        <label>Phone (Cellular)</label>
        <input type="text" id="phone_cell" name="phone_cell" placeholder="" value="{{{ $patientData->phone_cell }}}" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
        <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
      </div>

      <div class="small-12 medium-4 large-5 end columns">
        <label>Fax</label>
        <input type="text" id="employee_fax" name="employee_fax" placeholder="" value="{{{ $patientExtraInfo->employee_fax }}}" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
        <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
      </div>
    </div> 



    <div class="row">
      <div class="large-12 columns">
        <hr>
        <h2>Patient Address</h2>
        <p>
          <label>
            N/A
            <input type="checkbox"  id="checkAddress" name="checkAddress" onchange="javascript:showContent();"/>
          </label>
        </p>
      </div>

      <div class="row">
        <div id="proxyAddress" style="display:none;" class="large-12 columns">
          <label>Proxy address</label>
          <input type="checkbox" id="checkProxy"  name="proxy_address" value="1" onchange="javascript:proxyAddress();"/>                  
        </div>
      </div>

      <div id="proxy" style="display:none;" >

        <div class="row">
          <div class="small-12 medium-9 large-9 columns">
            <label>Address 1</label>
            <strong>{{{$provider->street}}}</strong>
          </div>
        </div>
        <div class="row">
          <div class="small-12 medium-9 large-9 columns">
            <label>Address 2</label>
            <strong>{{{$provider->streetb}}}</strong>
          </div>
        </div>
        <div class="row">
          <div class="small-12 medium-9 large-9 columns">
            <label>City</label>
            <strong>{{{$provider->city}}}</strong>
          </div>
        </div>
        <div class="row">
          <div class="small-12 medium-5 large-5 columns">
            <label>State</label>
            <strong>{{{$provider->state}}}</strong>
          </div>
          <div class="small-12 medium-4 large-4 columns end">
            <label>Zipcode</label>
            <strong>{{{$provider->zip}}}</strong>
          </div>  
        </div>

      </div>

      <div id="address"  >

        <div class="row">
          <div class="small-12 medium-12 large-12 columns">
            <label>Address 1</label>
            <input type="text" id="address1" name="address1" placeholder="" required value="{{{ $patientData->street }}}" />
            <small class="error" data-error-message>Street is required and must be a string.</small>
          </div>

        </div>

        <div class="row">
          <div class="small-12 medium-12 large-12 end columns">
            <label>Address 2</label>
            <input type="text" id="address2" name="address2" placeholder="" value="{{{ $patientExtraInfo->address2 }}}" />
            <small class="error" data-error-message>Street is required and must be a string.</small>
          </div>
        </div>

        <div class="row">
          <div class="small-12 medium-4 large-4 columns">
            <label>City</label>
            <input type="text" id="city" name="city" placeholder="" value="{{{ $patientData->city }}}"  />
            <small class="error" data-error-message>Must be a string.</small>
          </div>
          <div class="small-12 medium-4 large-4 columns">
            <label>State</label>
                    <!-- <input type="text" id="state" name="state" placeholder="" value="{{{ $patientData->state }}}"/>
                      <small class="error" data-error-message>Must be a string.</small> -->

                      <select id="state" name="state" >
                        <option value="AL"  >Alabama</option>
                        <option value="AK" >Alaska</option>
                        <option value="AZ" >Arizona</option>
                        <option value="AR" >Arkansas</option>
                        <option value="CA" >California</option>
                        <option value="CO" >Colorado</option>
                        <option value="CT" >Connecticut</option>
                        <option value="DE" >Delaware</option>
                        <option value="DC" >District Of Columbia</option>
                        <option value="FL" >Florida</option>
                        <option value="GA" >Georgia</option>
                        <option value="HI" >Hawaii</option>
                        <option value="ID" >Idaho</option>
                        <option value="IL" >Illinois</option>
                        <option value="IN" >Indiana</option>
                        <option value="IA" >Iowa</option>
                        <option value="KS" >Kansas</option>
                        <option value="KY" >Kentucky</option>
                        <option value="LA" >Louisiana</option>
                        <option value="ME" >Maine</option>
                        <option value="MD" >Maryland</option>
                        <option value="MA" >Massachusetts</option>
                        <option value="MI" >Michigan</option>
                        <option value="MN" >Minnesota</option>
                        <option value="MS" >Mississippi</option>
                        <option value="MO" >Missouri</option>
                        <option value="MT" >Montana</option>
                        <option value="NE" >Nebraska</option>
                        <option value="NV" >Nevada</option>
                        <option value="NH" >New Hampshire</option>
                        <option value="NJ" >New Jersey</option>
                        <option value="NM" >New Mexico</option>
                        <option value="NY" >New York</option>
                        <option value="NC" >North Carolina</option>
                        <option value="ND" >North Dakota</option>
                        <option value="OH" >Ohio</option>
                        <option value="OK" >Oklahoma</option>
                        <option value="OR" >Oregon</option>
                        <option value="PA" >Pennsylvania</option>
                        <option value="RI" >Rhode Island</option>
                        <option value="SC" >South Carolina</option>
                        <option value="SD" >South Dakota</option>
                        <option value="TN" >Tennessee</option>
                        <option value="TX" >Texas</option>
                        <option value="UT" >Utah</option>
                        <option value="VT" >Vermont</option>
                        <option value="VA" >Virginia</option>
                        <option value="WA" >Washington</option>
                        <option value="WV" >West Virginia</option>
                        <option value="WI" >Wisconsin</option>
                        <option value="WY" >Wyoming</option>
                        <option value="N/A" >N/A</option>
                      </select>
                    </div>
                    <div class="small-12 medium-4 large-4 end columns">
                      <label>Zipcode</label>
                      <input type="text" id="postal_code" name="postal_code" placeholder="" pattern="[0-9]{5}" required value="{{{ $patientData->postal_code }}}"/>
                      <small class="error" data-error-message>Zipcode is required. Five numbers</small>
                    </div>

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

                </div>

            <!-- <div class="row">
                <div class="small-12 medium-4 large-4 columns">
                  <label>Provider</label>
                  <input type="text" placeholder="" id="provider" name="provider" value="{{{ $patientExtraInfo->provider }}}"  required />
                  <small class="error" data-error-message>Provider is required</small>
                </div>
              </div> -->




              <hr>
              <div class="row">
                <div class="small-12 large-12 columns">
                  <div class="row">
                    <div class="small-12 large-12 columns">
                      <h2>Notification Preferences</h2>
                    </div>
                  </div>

                  <div class="row">

                    <div class="small-12 large-4 columns">
                      <label>E-mail <input type="radio" name="notification_preferences" checked value="email" /></label>
                    </div>
                    <div class="small-12 large-4 columns">
                      <label>Fax <input type="radio" name="notification_preferences"  value="fax" /></label>
                    </div>
                    <div class="small-12 large-4 columns">
                      <label>Text <input type="radio" name="notification_preferences"   value="sms" /></label>
                    </div>

                  </div>
                  <div class="row">
                    <div class="small-12 medium-6 large-6 columns">
                      <label>Preferred Language
                        @if(isset($patientExtraInfo->employee_language))
                        (Current - {{{$patientExtraInfo->employee_language}}})
                        @endif
                      </label>
                      <select id="employee_language" name="employee_language">
                        <option value="English"  >English</option>
                        <option value="Spanish"  >Spanish</option>
                      </select>
                    </div> 
                  </div>
                </div>
              </div>

              <hr>
              <div class="row">
                <div class="small-12 large-12 columns">
                  <h2>Notification and Contact Preferences</h2>
                </div>
              </div>

              <div class="row">

                <div class="small-12 large-4 columns">
                  <label>E-mail <input type="radio" name="emp_notification_preferences" checked value="email" /></label>
                </div>
                <div class="small-12 large-4 columns">
                  <label>Fax <input type="radio" name="emp_notification_preferences"  value="fax" /></label>
                </div>
                <div class="small-12 large-4 columns">
                  <label>Text <input type="radio" name="emp_notification_preferences"   value="sms" /></label>
                </div>

              </div>  
              <div class="row">
                <div class="small-12 medium-12 large-12 columns">                  
                  <label>Contact</label>
                  <input type="text" id="name_contact" name="name_contact" placeholder="" required value="{{{ $patientExtraInfo->contact }}}" />
                  <small class="error" data-error-message>Contact is required</small>
                </div>
              </div>
              <div class="row">
                <div class="small-12 medium-4 large-4 columns">
                  <label>Contact Email</label>
                  <input type="email" id="email_contact" name="email_contact" required placeholder="" value="{{{ $patientExtraInfo->contact_email }}}" />
                  <small class="error" data-error-message>Contact Email is required with email format.</small>
                </div>
                <div class="small-12 medium-4 large-4 columns">
                  <label>Contact Phone</label>
                  <input type="text" id="contact_phone" name="phone_contact" placeholder="" required value="{{{ $patientData->phone_contact }}}" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
                  <small class="error" data-error-message>Contact Phone is required, format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
                </div>
                <div class="small-12 medium-4 large-4 end columns">
                  <label>Fax</label>
                  <input type="text" id="fax" name="fax" placeholder="" value="{{{ $patientExtraInfo->fax }}}" />
                </div>
              </div>
              <div class="row">
                <div class="small-12 medium-6 large-6 columns">
                  <label>Preferred Language
                    @if(isset($patientExtraInfo->language))
                    (Current - {{{$patientExtraInfo->language}}})
                    @endif
                  </label>
                  <select id="language" name="language">
                    <option value="English"  >English</option>
                    <option value="Spanish"  >Spanish</option>
                  </select>
                </div> 
              </div>
            </div>

            <div class="row">
              <div class="large-12 columns">
                <hr>
                <h2>Employer Information</h2>
              </div>
            </div>

            <div class="row">
              <div class="small-12 medium-12 large-12 columns">
                <label>Name</label>
                <input type="text" id="employer" name="employer" placeholder="" required value="" />
                <small class="error" data-error-message>Employer Name is required</small>
              </div>
            </div>

            <div class="row">
              <div class="small-12 medium-12 large-12 columns">
                <label>Address1</label>
                <input type="text" id="employer_address" name="employer_address" placeholder="" required  value=""  />
                <small class="error" data-error-message>Street is required and must be a string.</small>
              </div>
            </div>

            <div class="row">
              <div class="small-12 medium-12 large-12 columns">
                <label>Address2</label>
                <input type="text" id="employer_address2" name="employer_address2" placeholder=""  value="{{{ $patientExtraInfo->employer_address2 }}}"  />
                <small class="error" data-error-message>Street is required and must be a string.</small>
              </div>
            </div>              

            <div class="row">
              <div class="small-12 medium-4 large-4 columns">
                <label>City</label>
                <input type="text" id="employer_city" name="employer_city" placeholder="" required value="" />
                <small class="error" data-error-message>Must be a string.</small>
              </div>
              <div class="small-12 medium-4 large-4 columns">
                <label>State</label>
                <select id="employer_state" name="employer_state">

                  <option value="AL" >Alabama</option>
                  <option value="AK" >Alaska</option>
                  <option value="AZ" >Arizona</option>
                  <option value="AR" >Arkansas</option>
                  <option value="CA" >California</option>
                  <option value="CO" >Colorado</option>
                  <option value="CT" >Connecticut</option>
                  <option value="DE" >Delaware</option>
                  <option value="DC" >District Of Columbia</option>
                  <option value="FL" >Florida</option>
                  <option value="GA" >Georgia</option>
                  <option value="HI" >Hawaii</option>
                  <option value="ID" >Idaho</option>
                  <option value="IL" >Illinois</option>
                  <option value="IN" >Indiana</option>
                  <option value="IA" >Iowa</option>
                  <option value="KS" >Kansas</option>
                  <option value="KY" >Kentucky</option>
                  <option value="LA" >Louisiana</option>
                  <option value="ME" >Maine</option>
                  <option value="MD" >Maryland</option>
                  <option value="MA" >Massachusetts</option>
                  <option value="MI" >Michigan</option>
                  <option value="MN" >Minnesota</option>
                  <option value="MS" >Mississippi</option>
                  <option value="MO" >Missouri</option>
                  <option value="MT" >Montana</option>
                  <option value="NE" >Nebraska</option>
                  <option value="NV" >Nevada</option>
                  <option value="NH" >New Hampshire</option>
                  <option value="NJ" >New Jersey</option>
                  <option value="NM" >New Mexico</option>
                  <option value="NY" >New York</option>
                  <option value="NC" >North Carolina</option>
                  <option value="ND" >North Dakota</option>
                  <option value="OH" >Ohio</option>
                  <option value="OK" >Oklahoma</option>
                  <option value="OR" >Oregon</option>
                  <option value="PA" >Pennsylvania</option>
                  <option value="RI" >Rhode Island</option>
                  <option value="SC" >South Carolina</option>
                  <option value="SD" >South Dakota</option>
                  <option value="TN" >Tennessee</option>
                  <option value="TX" >Texas</option>
                  <option value="UT" >Utah</option>
                  <option value="VT" >Vermont</option>
                  <option value="VA" >Virginia</option>
                  <option value="WA" >Washington</option>
                  <option value="WV" >West Virginia</option>
                  <option value="WI" >Wisconsin</option>
                  <option value="WY" >Wyoming</option>
                  <option value="N/A" >N/A</option>
                </select>
              </div>
              <div class="small-12 medium-4 large-4 columns">
                <label>Zipcode</label>
                <input type="text" id="employer_postal_code" name="employer_postal_code" placeholder="" required value=""/>
                <small class="error" data-error-message>Zipcode is required.</small>
              </div>

            </div>

            <div class="row">
              <div class="small-12 medium-4 large-5 columns">
                <label>Email</label>
                <input type="email" id="employer_email" name="employer_email" required value=""  placeholder="" />
                <small class="error" data-error-message>Invalid email format.</small>

              </div>
              <div class="small-12 medium-4 large-5 end columns">
                <label>Phone (Home)</label>
                <input type="text" id="employer_phone_home" name="employer_phone_home" value=""  placeholder="" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
                <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
              </div>
            </div>

            <div class="row">
             <div class="small-12 medium-4 large-5 columns">
              <label>Phone (Cellular)</label>
              <input type="text" id="employer_phone_cell" name="employer_phone_cell" value=""  placeholder="" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
              <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
            </div>

            <div class="small-12 medium-4 large-5 end columns">
              <label>Fax</label>
              <input type="text" id="employer_fax" name="employer_fax" value=""  placeholder="" pattern="^(?:\(\d{3}\)|\d{3})[- ]?\d{3}[- ]?\d{4}$" />
              <small class="error" data-error-message>Phone format:<br> (xxx)xxx-xxxx or xxx-xxx-xxxx</small>
            </div>
          </div> 


          <div class="row">
            <div class="small-12 medium-12 large-12 end columns">
              <label>Occupation / Company</label>
              <input type="text" id="employer_occupation" name="employer_occupation" placeholder="" required  value="{{{ $patientData->occupation }}}" />
              <small class="error" data-error-message>Ocupation / Company is required.</small>
            </div>
            <div class="large-12 columns">
              <hr>
            </div>
          </div>

          <div class="row">
            <div class="small-6 medium-6 large-6 columns">
              <button class="expand">Save</button>
            </div>
            <div class="small-6 medium-6 large-6 columns">
              <a href="{{{ URL::to('patients/' . $patientData->pid) }}}" class="button expand">Cancel</a>
            </div>
          </div>

          <!-- </form> -->
        </div>

        {{ Form::close() }}

        <!--  </form> -->

      </div>

      <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();
         
       })(jQuery);
     </script>


     @stop