streamline-emr/docker/streamline-src/Modules/ClinicalData/Resources/views/symptoms/create.blade.php

@extends('layouts.main')
@push('styles')
    <link href="{{ asset('elite/bower_components/icheck/skins/all.css') }}" rel="stylesheet">
@endpush

@section('content')
<div class="row bg-title">
    <div class="col-lg-3 col-md-4 col-sm-4 col-xs-12">
        <h4 class="page-title">{{ __('symptoms.add_symptom') }}</h4>
    </div>
    <div class="col-lg-9 col-sm-8 col-md-8 col-xs-12">
        <ol class="breadcrumb">
            <li><a href="{{ route('home') }}">{{ __('symptoms.dashboard') }}</a></li>
            <li><a href="{{ route('clinical_data.index') }}">{{ __('symptoms.clinical_data_home') }}</a></li>
            <li><a href="{{ route('symptoms.index') }}">{{ __('symptoms.symptoms') }}</a></li>
            <li class="active">{{ __('symptoms.create') }}</li>
        </ol>
    </div>
</div>

@include('clinical_data::symptoms.menu')

<div class="row">
    <div class="col-sm-12">
        <!--Flash messages at the top -->
        @include('flash::message')
        <div class="white-box">
            {{ Form::open(['route' => 'symptoms.store', 'data-toggle' => 'validator']) }}
            
            <div class="row">
                <div class="col-sm-6">
                    <div class="form-group">
                        {{ Form::label('name', __('symptoms.symptom')) }}
                        {{ Form::text('name', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('prompts', __('symptoms.prompt')) }}
                        {{ Form::textArea('prompts', '', ['class' => 'form-control', 'rows' => 5]) }}
                    </div>
                </div>
                <div class="col-sm-6">
                    <div class="form-group">
                        {{ Form::label('reference_text', __('symptoms.reference_area')) }}
                        <div class="row">
                            <div class="col-sm-4">
                                {{ Form::text('reference_text[]', '', ['class'=>'form-control', 'placeholder' => 'reference name']) }}
                            </div>
                            <div class="col-sm-8">
                                {{ Form::url('reference_link[]', '', ['class'=>'form-control', 'placeholder' => 'eg http://www.google.com']) }}
                            </div>                            
                            <div class="col-sm-12 input_fields_wrap"></div>
                            <div class="col-sm-12"><a class="add_field_button" style="color: blue;">{{ __('symptoms.add_more') }}</a></div>
                        </div>
                    </div>
                    <div class="form-group">
                        {{ Form::label('', __('symptoms.is_symptom_available'), ["class"=>'col-md-12']) }}
                        &nbsp;{{ __('symptoms.yes') }} {{ Form::radio('available', 1, false,  ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}
                        &nbsp;{{ __('symptoms.no') }} {{ Form::radio('available', 0, false, ["required", 'class' => 'check form-control', 'data-radio'=>'iradio_flat-green']) }}
                        <div class="help-block with-errors"></div>
                    </div>
                </div>
            </div>
            

            

            {{ Form::button(__('symptoms.submit'),['type'=>'submit','class'=>'btn btn-success btn-rounded waves-effect waves-light m-r-10']) }}
            {{ Form::button(__('symptoms.cancel'),['type'=>'reset','class'=>'btn btn-default btn-rounded waves-effect waves-light']) }}

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

@push('scripts')
<script src="{{ asset('elite/js/validator.js') }}"></script>
<!-- icheck -->
<script src="{{ asset('elite/bower_components/icheck/icheck.min.js') }}"></script>
<script src="{{ asset('elite/bower_components/icheck/icheck.init.js') }}"></script>
<script type="text/javascript">
    $(document).ready(function () {
        var max_fields = 4; //maximum input boxes allowed
        var wrapper = $(".input_fields_wrap"); //Fields wrapper
        var add_button = $(".add_field_button"); //Add button ID

        var x = 1; //initlal text box count
        $(add_button).click(function (e) { //on add input button click
            e.preventDefault();
            if (x < max_fields) { //max input box allowed
                x++; //text box increment
                $(wrapper).append('<div class="row"><br><br><br><div class="col-sm-4"><input type="text" class="form-control" placeholder="Reference name" name="reference_text[]"/></div>' +
                        '<div class="col-sm-7"><input type="url" placeholder="eg http://www.google.com" class="form-control" name="reference_link[]"/></div>'
                        + '<a href="#" class="remove_field" style="color: maroon"><sup>X</sup></a></div>'); //add input box
            }
        });

        $(wrapper).on("click", ".remove_field", function (e) { //user click on remove text
            e.preventDefault();
            $(this).parent('div').remove();
            x--;
        })
    });
</script>
@endpush