239 lines
14 KiB
PHP
239 lines
14 KiB
PHP
<!DOCTYPE html>
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<html lang="{{ str_replace('_', '-', app()->getLocale()) }}">
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<head>
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@include('layout.header')
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</head>
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<body>
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<div class="container-scroller">
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@include('layout.navbar')
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<!-- partial -->
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@include('layout.breadscrum')
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<div class="container-fluid page-body-wrapper">
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@include('layout.sidebar')
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<!-- partial -->
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<div class="main-panel">
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<div class="content-wrapper">
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<div class="row">
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<div class="col-md-12 grid-margin stretch-card">
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<div class="card">
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<div class="card-body">
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<h4 class="card-title"><i class="mdi mdi-dots-vertical menu-icon"></i> Patient Register</h4><hr class="my-3">
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<div class="col-12">
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<form class="form">
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<div class="row">
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<div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 col-xl-6">
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<div class="form-group row my-2">
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<label for="patient_name" class="col-sm-12 col-md-3 col-form-label">Patient-Code<code> *</code></label>
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<div class="col-12 col-sm-12 col-md-9">
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<input id="patient_name" class="form-control" name="patient_name" type="text" placeholder="Patient code" required="" autocomplete="off">
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="patient_name" class="col-sm-12 col-md-3 col-form-label">Patient-Name<code> *</code></label>
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<div class="col-12 col-sm-12 col-md-9">
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<input id="patient_name" class="form-control" name="patient_name" type="text" placeholder="Patient name" required="" autocomplete="off">
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="example-text-input" class="col-sm-12 col-md-3 col-form-label">Dob <b>or</b> Age<code> *</code></label>
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<div class="col-12 col-sm-12 col-md-9">
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<div class="input-group">
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<div class="input-group-append">
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<input class="form-control" name="dob" type="text" id="dob" placeholder="{{__('general.date_placeholder')}}" required="" autocomplete="off">
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</div>
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<input type="number" id="age" name="age" placeholder="Age" value="" class="form-control" autocomplete="off">
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<div class="input-group-append">
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<select class="form-control" name="age_from_unit" id="age-from-unit">
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<option value="1">Day</option>
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<option value="30">Month</option>
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<option value="365">Year</option>
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</select>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="Gender" class="col-md-3 col-form-label">Gender<code> *</code></label>
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<div class="col-md-9 row pl-4" style="padding-top:7px;">
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="gender" data-id="1" value="1"> Male
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</label>
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</div>
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="gender" data-id="2" value="2"> Female
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</label>
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</div>
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="gender" data-id="3" value="3"> Other
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</label>
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</div>
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="Gender" class="col-md-3 col-form-label">Marital Status<code> *</code></label>
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<div class="col-md-9 row pl-4" style="padding-top:7px;">
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="marital_status" data-id="1" value="1"> Single
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</label>
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</div>
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="marital_status" data-id="2" value="2"> Married
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</label>
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</div>
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<div class="form-check col-sm-4">
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<label class="form-check-label">
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<input type="radio" class="form-check-input" name="marital_status" data-id="3" value="3"> Other
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</label>
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</div>
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</div>
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</div>
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</div>
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<div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 col-xl-6 pb-4">
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<div class="form-group row">
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<label for="example-text-input" class="col-md-3 col-form-label">Phone Number<code> *</code></label>
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<div class="col-md-9">
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<input class="form-control" type="text" placeholder="099 999 999" name="phone" required="" autocomplete="off">
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="example-text-input" class="col-md-3 col-form-label">Province<code></code></label>
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<div class="col-md-9">
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<select class="form-control select2" name="province_id" id="province-id" style="width: 100% !important;">
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<option></option>
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@foreach($provinces as $province)
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<option value="{{$province->id}}">{{$province->name_en}}</option>
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@endforeach
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</select>
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="example-text-input" class="col-md-3 col-form-label">District<code></code></label>
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<div class="col-md-9">
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<select class="form-control select2" name="district_id" id="district-id" style="width: 100% !important;">
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</select>
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="example-text-input" class="col-md-3 col-form-label">Commune</label>
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<div class="col-md-9">
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<select class="form-control select2" name="commune_id" id="commune-id" style="width: 100% !important;">
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</select>
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</div>
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</div>
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<div class="form-group row my-2">
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<label for="example-text-input" class="col-md-3 col-form-label">Village</label>
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<div class="col-md-9">
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<select class="form-control select2" name="village_id" id="village-id" style="width: 100% !important;">
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</select>
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</div>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-sm-12 float-right">
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<button type="submit" class="btn btn-info"><i class="fa fa-floppy-o"></i> <span class="save">{{__('lang.save')}}</span><span class="update" style="display: none">{{__('lang.update')}}</span></button>
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<button type="button" class="btn btn-light" data-dismiss='modal'>{{__('lang.cancel')}}</button>
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</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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@include('layout.footer')
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</div>
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</div>
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</div>
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@include('layout.common_script')
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<script>
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$('#province-id').change(function () {
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$.ajax({
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url:"{{url('districts/json')}}/"+$(this).val(),
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type:"GET",
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dataType:"json",
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success:function(response){
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$('#district-id').html('');
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response.map(item =>{
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var patientOption = document.createElement('OPTION');
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patientOption.setAttribute('value',item.id);
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patientOption.text = item.name_en;
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$('#district-id').append(patientOption);
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})
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$('#district-id').append('<option selected></option>');
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},
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error: function(response) {
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},
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});
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})
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$('#district-id').change(function () {
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$.ajax({
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url:"{{url('communes/json')}}/"+$(this).val(),
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type:"GET",
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dataType:"json",
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success:function(response){
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$('#commune-id').html('');
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response.map(item =>{
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var patientOption = document.createElement('OPTION');
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patientOption.setAttribute('value',item.id);
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patientOption.text = item.name_en;
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$('#commune-id').append(patientOption);
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})
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$('#commune-id').append('<option selected></option>');
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},
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error: function(response) {
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},
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});
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})
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$('#commune-id').change(function () {
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$.ajax({
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url:"{{url('villages/json')}}/"+$(this).val(),
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type:"GET",
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dataType:"json",
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success:function(response){
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$('#village-id').html('');
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response.map(item =>{
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var patientOption = document.createElement('OPTION');
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patientOption.setAttribute('value',item.id);
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patientOption.text = item.name_en;
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$('#village-id').append(patientOption);
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})
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$('#village-id').append('<option selected></option>');
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},
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error: function(response) {
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},
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});
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})
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</script>
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</body>
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</html>
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