@extends('layouts.main') @push('styles') @endpush @section('content')

{{ __('diagnoses.add_diagnosis') }}

@include('clinical_data::diagnoses.menu')
@include('flash::message')
{{ Form::open(['route' => 'diagnoses.store', 'data-toggle' => 'validator']) }}
{{ Form::label('name', __('diagnoses.diagnosis_name')) }} {{ Form::text('name', '', ['class' => 'form-control compulsory', 'required']) }}
@if (!empty($errors->get('name')))
@foreach ($errors->get('name') as $message) {{ $message }} @endforeach
@endif
{{ Form::label('icd10_code', __('diagnoses.icd_10_code')) }} {{ Form::text('icd10_code', '', ['class' => 'form-control']) }}

HMIS Outpatient Report (105)

{{ Form::select('outpatient_hmis_category', $outpatient_hmis_categories, '', ['class' => 'form-control compulsory', 'id'=>'outpatient_hmis_category', 'required']) }}
{{ Form::label('outpatient_dependent_option', 'Outpatient Dependent Option') }}
{{ Form::label('district_code', 'District Disease Code') }} {{ Form::text('district_code', '', ['class' => 'form-control', 'id'=>'district_code']) }}

HMIS Inpatient Report (108)

{{-- {{ Form::label('hmis_category', __('diagnoses.hmis_category')) }} --}} {{ Form::select('hmis_category', $inpatient_hmis_categories, '', ['class' => 'form-control compulsory', 'id'=>'hmis_category_inpatient', 'required']) }}
{{ Form::label('hmis_category_inpatient_options', __('diagnoses.hmis_inpatient_category')) }}
{{ Form::label('hysterectomy_type', 'Dependent Option') }}
@if(is_chi_enabled())
{{ Form::label('insurance_tariffs', 'Insurance Tariffs') }} {{ Form::select('insurance_tariffs[]', $insurance_tariffs,'',['id'=>'insurance_tariffs', 'multiple', 'class' => 'form-control']) }}
@endif
{{ Form::label('prompts', __('diagnoses.diagnosis_prompt')) }} {{ Form::textArea('prompts', '', ['class'=>'form-control', 'rows' => 5]) }}
{{ Form::label('', __('diagnoses.chronic_status'), ["class"=>'col-md-12']) }}  {{ __('diagnoses.yes') }} {{ Form::radio('chronic_status', 1, false, ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}  {{ __('diagnoses.no') }} {{ Form::radio('chronic_status', 0, false, ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}
{{ Form::label('available', __('diagnoses.is_diagnosis_available'), ["class"=>'col-md-12']) }}  {{ __('diagnoses.yes') }} {{ Form::radio('available', 1, false, ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}  {{ __('diagnoses.no') }} {{ Form::radio('available', 0, false, ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}
{{ Form::label('diagnosis_category', __('diagnoses.diagnosis_category')) }} {{ Form::select('diagnosis_category', $diagnosis_categories, '', ['class' => 'form-control']) }}
{{ Form::label('reference_areas', __('diagnoses.reference_areas')) }}


{{ Form::text('reference_names[]', '', ['class' => 'form-control', 'placeholder' => 'Reference name']) }}
{{ Form::text('reference_areas[]', '', ['class' => 'form-control', 'placeholder' => 'e.g. http://google.com']) }}


{{ __('diagnoses.add_more')}}

{{ Form::button(__('diagnoses.submit'),['type'=>'submit','class'=>'btn btn-success waves-effect waves-light m-r-10']) }} {{ Form::button(__('diagnoses.cancel'),['type'=>'reset','class'=>'btn btn-default waves-effect waves-light']) }} {{ Form::close() }}
@endsection @push('scripts') @endpush