@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">
        <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="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 class="row">
                  <div class="small-12 medium-4 large-4 columns">
                    <label>Phone</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 class="small-12 medium-4 large-4 end 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-4 end columns">
                    <label>Fax</label>
                    <input type="text" id="employee_fax" name="employee_fax" placeholder="" value="{{{ $patientExtraInfo->employee_fax }}}" />
                  </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" 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" 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-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