@extends('admin.layouts.app')

@section('content')
    <div class="content-body">
        <div class="container-fluid">
            <div class="page-titles">
                <ol class="breadcrumb">
                    <li class="breadcrumb-item"><a href="{{ route('lab.patient.index') }}">Patient</a></li>
                    <li class="breadcrumb-item active"><a href="javascript:void(0)">Create</a></li>
                </ol>
            </div>
            
          

            {!! Form::open([
                'route' => ['lab.patient.store'],
                'method' => 'post',
                'id' => 'ajax-submit',
                'files' => true,
            ]) !!}

            <div class="row pt-3">

                {{-- LEFT SIDE --}}
                <div class="col-xl-6">

                    {{-- Personal Information --}}
                    <div class="card overflow-hidden mb-4">

                        <div class="card-header">
                            <h4 class="card-title mb-0">
                                <i class="fa fa-user-circle me-2"></i>
                                Personal Information
                            </h4>
                        </div>

                        <div class="card-body p-4">
                            <div class="row">

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('first_name', 'First Name', ['class' => 'fw-bold mb-2']) !!}
                                    <div class="input-group">
                                        <span class="input-group-text bg-light">
                                            <i class="fa fa-user"></i>
                                        </span>
                                        {!! Form::text('first_name', null, [
                                            'class' => 'form-control',
                                            'placeholder' => 'Enter First Name',
                                        ]) !!}
                                    </div>
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('last_name', 'Last Name', ['class' => 'fw-bold mb-2']) !!}
                                    <div class="input-group">
                                        <span class="input-group-text bg-light">
                                            <i class="fa fa-user"></i>
                                        </span>
                                        {!! Form::text('last_name', null, [
                                            'class' => 'form-control',
                                            'placeholder' => 'Enter Last Name',
                                        ]) !!}
                                    </div>
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('gender', 'Gender', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::select(
                                        'gender',
                                        [
                                            'Male' => 'Male',
                                            'Female' => 'Female',
                                            'Other' => 'Other',
                                        ],
                                        null,
                                        [
                                            'class' => 'form-control select2',
                                            'placeholder' => 'Select Gender',
                                        ],
                                    ) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('date_of_birth', 'Date Of Birth', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::date('date_of_birth', null, [
                                        'class' => 'form-control',
                                    ]) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('phone', 'Phone', ['class' => 'fw-bold mb-2']) !!}
                                    <div class="input-group">
                                        <span class="input-group-text bg-light">
                                            <i class="fa fa-phone"></i>
                                        </span>
                                        {!! Form::text('phone', null, [
                                            'class' => 'form-control',
                                            'placeholder' => 'Enter Phone Number',
                                            'maxlength' => 10,
                                        ]) !!}
                                    </div>
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('email', 'Email', ['class' => 'fw-bold mb-2']) !!}
                                    <div class="input-group">
                                        <span class="input-group-text bg-light">
                                            <i class="fa fa-envelope"></i>
                                        </span>
                                        {!! Form::email('email', null, [
                                            'class' => 'form-control',
                                            'placeholder' => 'Enter Email Address',
                                        ]) !!}
                                    </div>
                                </div>

                                <div class="col-md-4 mb-3">
                                    {!! Form::label('city', 'City', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::text('city', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter City',
                                    ]) !!}
                                </div>

                                <div class="col-md-4 mb-3">
                                    {!! Form::label('marital_status', 'Marital Status', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::select(
                                        'marital_status',
                                        [
                                            'Single' => 'Single',
                                            'Married' => 'Married',
                                            'Divorced' => 'Divorced',
                                        ],
                                        null,
                                        [
                                            'class' => 'form-control select2',
                                            'placeholder' => 'Select Status',
                                        ],
                                    ) !!}
                                </div>

                                <div class="col-md-4 mb-3">
                                    {!! Form::label('zip_code', 'Zip Code', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::text('zip_code', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter Zip Code',
                                    ]) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('status', 'Status', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::select(
                                        'status',
                                        [
                                            1 => 'Active',
                                            0 => 'Inactive',
                                        ],
                                        old('status', $result->status ?? 1),
                                        [
                                            'class' => 'form-control select2',
                                            'placeholder' => 'Select Status',
                                        ],
                                    ) !!}
                                </div>

                                <div class="col-md-12 mb-3">
                                    {!! Form::label('address', 'Address', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::textarea('address', null, [
                                        'class' => 'form-control',
                                        'rows' => 3,
                                        'placeholder' => 'Enter Full Address',
                                    ]) !!}
                                </div>

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

                {{-- RIGHT SIDE --}}
                <div class="col-xl-6">

                    {{-- Health Information --}}
                    <div class="card overflow-hidden mb-4">

                        <div class="card-header">
                            <h4 class="card-title mb-0">
                                <i class="fa fa-heartbeat me-2"></i>
                                Health Information
                            </h4>
                        </div>

                        <div class="card-body p-4">

                            <div class="row">

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('blood_group', 'Blood Group', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::select(
                                        'blood_group',
                                        [
                                            'A+' => 'A+',
                                            'A-' => 'A-',
                                            'B+' => 'B+',
                                            'B-' => 'B-',
                                            'AB+' => 'AB+',
                                            'AB-' => 'AB-',
                                            'O+' => 'O+',
                                            'O-' => 'O-',
                                        ],
                                        null,
                                        [
                                            'class' => 'form-control select2',
                                            'placeholder' => 'Select Blood Group',
                                        ],
                                    ) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('occupation', 'Occupation', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::text('occupation', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter Occupation',
                                    ]) !!}
                                </div>

                                <div class="col-md-12 mb-3">
                                    {!! Form::label('allergies', 'Allergies', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::textarea('allergies', null, [
                                        'class' => 'form-control',
                                        'rows' => 3,
                                        'placeholder' => 'Enter Allergies',
                                    ]) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('aadhaar_number', 'Aadhaar Number', ['class' => 'fw-bold mb-2']) !!}
                                    {!! Form::text('aadhaar_number', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter Aadhaar Number',
                                        'maxlength' => 12,
                                    ]) !!}
                                </div>

                                <div class="col-md-6 mb-3">
                                    {!! Form::label('insurance_provider', 'Insurance Provider', [
                                        'class' => 'fw-bold mb-2',
                                    ]) !!}
                                    {!! Form::text('insurance_provider', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter Insurance Provider',
                                    ]) !!}
                                </div>

                                <div class="col-md-12 mb-3">
                                    {!! Form::label('insurance_number', 'Insurance Number', [
                                        'class' => 'fw-bold mb-2',
                                    ]) !!}
                                    {!! Form::text('insurance_number', null, [
                                        'class' => 'form-control',
                                        'placeholder' => 'Enter Insurance Number',
                                    ]) !!}
                                </div>

                            </div>

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

                {{-- Buttons --}}
                <div class="col-12">
                   

                            <button type="submit" class="btn btn-primary px-5 rounded-pill">
                                <i class="fa fa-save me-2"></i>
                                Save Patient
                            </button>

                            <a href="{{ route('lab.patient.index') }}"
                                class="btn btn-light border px-5 rounded-pill">
                                Cancel
                            </a>

                </div>

            </div>

            {!! Form::close() !!}
        </div>
    </div>
@endsection