<?php

use App\Models\Point;

$category = 'COVID_INTAKE';

if(!@$sessionKey) {
    $sessionKey = request()->cookie('sessionKey');
}

$point = Point::getOrCreateOnlyTopLevelPointOfCategory($note, 'COVID_INTAKE', $sessionKey, true);

$contentData = [

	"ans_cdc_guidelines_aarp_mental_health" => '',
	"ans_follow_up_scheduled" => '',

    "ans_how_are_you" => '',
    "ans_is_address_correct" => null, // yes/no
    "ans_corrected_address" => '',
    "ans_has_worked_with_an_np_before" => null, // yes/no
    "ans_has_worked_with_an_np_before_expl_feedback" => null, // yes/no
    "ans_goal_expl_feedback" => null, // yes/no
    "ans_quick_intake_expl_feedback" => null, // yes/no
    "ans_normal_temp_is_986" => null, // yes/no
    "ans_baseline_expl_feedback_1" => null, // yes/no
    "ans_baseline_expl_feedback_2" => null, // yes/no

    "ans_baseline_temperature" => '',
    "ans_currently_running_high" => '',

    "ans_baseline_blood_ox" => '',
    "ans_blood_ox_by_self" => '', // yes/no
    "ans_blood_ox_expl_feedback" => null, // yes/no
    "ans_blood_ox_condition_covid" => null, // yes/no
    "ans_condition_covid_how_now" => '',
    "ans_condition_covid_recovered" => '',
    "ans_condition_covid_lingering_symptoms" => '',
    "ans_blood_ox_condition_asthma" => null, // yes/no
    "ans_condition_asthma_how_now" => '',
    "ans_condition_asthma_recovered" => '',
    "ans_condition_asthma_lingering_symptoms" => '',
    "ans_blood_ox_condition_copd" => null, // yes/no
    "ans_condition_copd_how_now" => '',
    "ans_condition_copd_recovered" => '',
    "ans_condition_copd_lingering_symptoms" => '',
    "ans_blood_ox_condition_other" => '',
    "ans_condition_other_how_now" => '',
    "ans_condition_other_recovered" => '',
    "ans_condition_other_lingering_symptoms" => '',

    "ans_baseline_heart_rate" => '',
    "ans_baseline_bp" => '',
    "ans_bp_by_self" => '', // yes/no
    "ans_high_bp_ever" => null, // yes/no
    "ans_bp_medicine" => null, // yes/no
    "ans_bp_medicine_1_type" => '',
    "ans_bp_medicine_1_dose" => '',
    "ans_bp_medicine_2_type" => '',
    "ans_bp_medicine_2_dose" => '',
    "ans_bp_medicine_3_type" => '',
    "ans_bp_medicine_3_dose" => '',
    "ans_cardiac_heart_ever_cad" => null, // yes/no
    "ans_cardiac_heart_ever_irr" => null, // yes/no
    "ans_cardiac_heart_ever_chf" => null, // yes/no
    "ans_cardiac_heart_ever_other" => '',
    "ans_chest_pain" => null, // yes/no
    "ans_shortness_of_breath" => null, // yes/no
    "ans_fatigue" => null, // yes/no
    "ans_headache" => null, // yes/no,
    "ans_increase_in_heart_rate" => null, // yes/no,
    "ans_increase_in_heart_rate_frequency" => '',
    "ans_monitor_bp_before_after_workouts" => null, // yes/no,

    "ans_covid_vaccine" => null, // yes/no,
    "ans_covid_vaccine_no_long_term_safety" => '',
    "ans_covid_vaccine_no_short_term_side_effects" => '',
    "ans_covid_vaccine_no_logistic_issues" => '',
    "ans_covid_vaccine_no_covid19_doubts" => '',
    "ans_covid_vaccine_no_vaccine_efficacy_doubts" => '',
    "ans_covid_vaccine_no_other" => '',
    "ans_covid_vaccine_yes_which" => '',
    "ans_covid_vaccine_yes_dose1_date" => '',
    "ans_covid_vaccine_yes_dose2_date" => '',
    "ans_covid_vaccine_dose1_symptoms" => '',
    "ans_covid_vaccine_dose1_symptoms_start" => '',
    "ans_covid_vaccine_dose1_symptoms_duration" => '',
    "ans_covid_vaccine_dose1_symptoms_medications" => '',
    "ans_covid_vaccine_dose1_symptoms_any_from_list" => '',
    "ans_covid_vaccine_dose2_symptoms" => '',
    "ans_covid_vaccine_dose2_symptoms_start" => '',
    "ans_covid_vaccine_dose2_symptoms_duration" => '',
    "ans_covid_vaccine_dose2_symptoms_medications" => '',
    "ans_covid_vaccine_dose2_symptoms_any_from_list" => '',
    "ans_covid_help_for_vaccination" => '',
    "ans_covid_cdc_checklist_vaccinated_social_gatherings" => null, // yes/no
    "ans_covid_cdc_checklist_vaccinated_social_distancing" => null, // yes/no
    "ans_covid_cdc_checklist_vaccinated_mask_wearing" => null, // yes/no
    "ans_covid_cdc_checklist_vaccinated_hand_washing" => null, // yes/no
    "ans_covid_cdc_checklist_vaccinated_face_rubbing" => null, // yes/no
    "ans_covid_cdc_checklist_not_vaccinated_social_gatherings" => null, // yes/no
    "ans_covid_cdc_checklist_not_vaccinated_social_distancing" => null, // yes/no
    "ans_covid_cdc_checklist_not_vaccinated_mask_wearing" => null, // yes/no
    "ans_covid_cdc_checklist_not_vaccinated_hand_washing" => null, // yes/no
    "ans_covid_cdc_checklist_not_vaccinated_face_rubbing" => null, // yes/no

    "ans_plan_reported_only_baseline_vitals" => null, // checkbox
    "ans_plan_instructed_cdc_guidelines" => null, // checkbox
    "ans_plan_not_vaccinated_advised_to_get_vaccinated" => null, // checkbox
    "ans_plan_not_vaccinated_advised_vaccine_safety" => null, // checkbox
    "ans_plan_not_vaccinated_stressed_vaccine_benefits" => null, // checkbox
    "ans_plan_not_vaccinated_discussed_barriers_to_vaccination" => null, // checkbox
    "ans_plan_not_vaccinated_all_qns_answered" => null, // checkbox
    "ans_plan_1_dose_encouraged_to_get_2nd_dose" => null, // checkbox
    "ans_plan_1_dose_explained_antibody_development" => null, // checkbox
    "ans_plan_1_dose_discussed_barriers_to_vaccination" => null, // checkbox
    "ans_plan_1_dose_all_qns_answered" => null, // checkbox
    "ans_plan_ls_patient_confirms_understanding_ls_mods" => null, // checkbox
    "ans_plan_ls_patient_elects_supervised_ls_mods" => null, // checkbox
    "ans_plan_ls_explained_exercise_risks" => null, // checkbox
    "ans_plan_ls_instructed_bp_random_times_daily" => null, // checkbox

    "ans_vaccine_status_not_enough_rapport" => null, // checkbox
    "ans_vaccine_status_declined_to_answer" => null, // checkbox
    "ans_vaccine_status" => '',

    "ans_booster_status_not_enough_rapport" => null, // checkbox
    "ans_booster_status_declined_to_answer" => null, // checkbox
    "ans_booster_status" => '',

    "ans_current_behaviors_to_stay_safe" => '',
    "ans_total_mins_spent" => '',

    "ans_edu_provided_use_of_smd" => null, // checkbox
    "ans_edu_provided_asymptomatic_hypoxia" => null, // checkbox
    "ans_edu_provided_cdc_guidelines" => null, // checkbox
    "remarks" => null,

];

if ($point->lastChildReview && $point->lastChildReview->data) {
    $point->lastChildReview->data = json_decode($point->lastChildReview->data, true);
    $contentData = $point->lastChildReview->data;
}

?>

<div visit-moe close-on-save close-on-cancel class="d-block p-3 popup-content-container" id="edit-module-covid-intake">
    <form show url="/api/visitPoint/upsertChildReview" class="mcp-theme-1">
        <input type="hidden" name="uid" value="<?= $point->uid ?>">
        <input type="hidden" name="noteUid" value="<?= $note->uid ?>">
        <input type="hidden" name="segmentUid" value="<?= $segment->uid ?>">
        <input type="hidden" name="data" value="{{json_encode($contentData)}}">
        <p class="mb-2">Hi {{strtolower($patient->sex) === 'M' ? 'Mr.' : 'Mrs.'}} {{$patient->displayName()}}, My name is {{$pro->displayName()}}. I'm a board-certified nurse practitioner.</p>

        <div class="mb-2">
            <label class="mb-1">How are you?</label>
            <textarea data-name="ans_how_are_you" class="form-control form-control-sm" rows="2">{{ @$contentData['ans_how_are_you'] }}</textarea>
        </div>

        <hr class="my-3">

        <div class="mb-2">
            <?php
            $mailingAddress = implode(' ', [$patient->mailing_address_line1, $patient->mailing_address_line2, $patient->mailing_address_city, $patient->mailing_address_state, $patient->mailing_address_zip]);
            ?>
            <label class="mb-1">Let me confirm your mailing address: {{$mailingAddress}}</label>
            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_is_address_correct" name="ans_is_address_correct" {{@$contentData['ans_is_address_correct'] && @$contentData['ans_is_address_correct'] === 'yes' ? 'checked' : ''}} value="yes">
                    <span class="ml-1">Yes</span>
                </label>
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_is_address_correct" name="ans_is_address_correct" {{@$contentData['ans_is_address_correct'] && @$contentData['ans_is_address_correct'] === 'no' ? 'checked' : ''}} value="no">
                    <span class="ml-1">No</span>
                </label>
            </div>
        </div>

        <div class="mb-2">
            <label class="mb-1">If different from above:</label>
            <textarea data-name="ans_corrected_address" class="form-control form-control-sm" rows="1">{{ @$contentData['ans_corrected_address'] }}</textarea>
        </div>

        <hr class="my-3">

        <div class="mb-2 d-none">
            So it'll be my responsibility to ensure that you know exactly how to use the kit once you get it.
        </div>

        <div class="mb-2">
            <label class="mb-1">Have you ever worked with a nurse practitioner before?</label>
            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_has_worked_with_an_np_before" name="ans_has_worked_with_an_np_before" {{@$contentData['ans_has_worked_with_an_np_before'] && @$contentData['ans_has_worked_with_an_np_before'] === 'yes' ? 'checked' : ''}} value="yes">
                    <span class="ml-1">Yes</span>
                </label>
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_has_worked_with_an_np_before" name="ans_has_worked_with_an_np_before" {{@$contentData['ans_has_worked_with_an_np_before'] && @$contentData['ans_has_worked_with_an_np_before'] === 'no' ? 'checked' : ''}} value="no">
                    <span class="ml-1">No</span>
                </label>
            </div>
        </div>

        <div class="mb-2 ml-3">
            <ul>
                <li><strong>I'M NOT HERE TO REPLACE YOUR CURRENT DOCTORS.</strong></li>
		<li>This is a telehealth service that you can rely on in addition to your existing care team if you ever need support after hours or have a question about one of your vital signs.</li>
                <li>Like medical doctors, we have the authority to write prescriptions and order labs.</li>
                <li>So if you ever need anything (medical advice, prescriptions, labs, etc.), you can always call me via phone.</li>
                <li>Or we can do video calls over Zoom if that's ever helpful.</li>
                <li>And because telemedicine is now covered by Medicare and we're allowed to waive co-pays, it's free of charge for patients.</li>
                <li>You'll never get a bill or anything.</li>
                <li>
                    <label class="mb-1"><b>Ok?</b></label>
                    <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                        <label class="my-0 mr-3 d-flex align-items-center">
                            <input type="radio" data-name="ans_has_worked_with_an_np_before_expl_feedback" name="ans_has_worked_with_an_np_before_expl_feedback" {{@$contentData['ans_has_worked_with_an_np_before_expl_feedback'] && @$contentData['ans_has_worked_with_an_np_before_expl_feedback'] === 'yes' ? 'checked' : ''}} value="yes">
                            <span class="ml-1">Yes</span>
                        </label>
                        <label class="my-0 mr-3 d-flex align-items-center">
                            <input type="radio" data-name="ans_has_worked_with_an_np_before_expl_feedback" name="ans_has_worked_with_an_np_before_expl_feedback" {{@$contentData['ans_has_worked_with_an_np_before_expl_feedback'] && @$contentData['ans_has_worked_with_an_np_before_expl_feedback'] === 'no' ? 'checked' : ''}} value="no">
                            <span class="ml-1">No</span>
                        </label>
                    </div>
                </li>
            </ul>
        </div>

        <div class="mb-2">
            Our goal right now is to help you stay healthy and monitor your most important vital signs at home during this pandemic.
        </div>
        <div class="mb-2 ml-3">
            <ul>
		<li>Recent surge in cases.</li>
                <li>
                    Self-monitoring your vitals is more important than ever these days because even though vaccines are really effective, there’s an ongoing risk of getting COVID even after vaccination.
                    <ul>
                        <li>It’s likely that COVID is going to become ‘endemic’ like the flu, where the virus is here to stay and change season to season.</li>
                        <li>So you do need a long-term strategy to protect yourself in addition to vaccines.</li>
                        <li>Small changes in your temperature or oxygen levels are extremely helpful in detecting COVID early, and early treatment is extremely effective at preventing hospitalization.</li>
                        <li>
                            <label class="mb-1"><b>Does that make sense?</b></label>
                            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                                <label class="my-0 mr-3 d-flex align-items-center">
                                    <input type="radio" data-name="ans_goal_expl_feedback" name="ans_goal_expl_feedback" {{@$contentData['ans_goal_expl_feedback'] && @$contentData['ans_goal_expl_feedback'] === 'yes' ? 'checked' : ''}} value="yes">
                                    <span class="ml-1">Yes</span>
                                </label>
                                <label class="my-0 mr-3 d-flex align-items-center">
                                    <input type="radio" data-name="ans_goal_expl_feedback" name="ans_goal_expl_feedback" {{@$contentData['ans_goal_expl_feedback'] && @$contentData['ans_goal_expl_feedback'] === 'no' ? 'checked' : ''}} value="no">
                                    <span class="ml-1">No</span>
                                </label>
                            </div>
                        </li>
                    </ul>
                </li>
            </ul>
        </div>

        <div class="mb-2">
            <label class="mb-1">So today we’re going to conduct a quick intake, I’m going to give you some important information, and then we’ll get you all set up. <b>Ok?</b></label>
            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_quick_intake_expl_feedback" name="ans_quick_intake_expl_feedback" {{@$contentData['ans_quick_intake_expl_feedback'] && @$contentData['ans_quick_intake_expl_feedback'] === 'yes' ? 'checked' : ''}} value="yes">
                    <span class="ml-1">Yes</span>
                </label>
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_quick_intake_expl_feedback" name="ans_quick_intake_expl_feedback" {{@$contentData['ans_quick_intake_expl_feedback'] && @$contentData['ans_quick_intake_expl_feedback'] === 'no' ? 'checked' : ''}} value="no">
                    <span class="ml-1">No</span>
                </label>
            </div>
        </div>

        <hr class="my-3">

        <div class="mb-1">
            So first we’re going to talk a little bit about the <b>baseline</b> numbers of your vital signs.
        </div>

        <div class="mb-1">
            Baseline means what is normal for <b>you</b>.
        </div>

        <div class="mb-2">
            <label class="mb-1">For example, have you heard that normal body temperature is 98.6 F?.</label>
            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_normal_temp_is_986" name="ans_normal_temp_is_986" {{@$contentData['ans_normal_temp_is_986'] && @$contentData['ans_normal_temp_is_986'] === 'yes' ? 'checked' : ''}} value="yes">
                    <span class="ml-1">Yes</span>
                </label>
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_normal_temp_is_986" name="ans_normal_temp_is_986" {{@$contentData['ans_normal_temp_is_986'] && @$contentData['ans_normal_temp_is_986'] === 'no' ? 'checked' : ''}} value="no">
                    <span class="ml-1">No</span>
                </label>
            </div>
        </div>

        <div class="mb-2 ml-3">
            <ul>
                <li>So, that’s the <b>average</b> for all humans.</li>
                <li>But everyone is unique. Some people run hotter and some run colder.</li>
                <li>Also, normal body temperature number goes <b>down</b> with age</li>
                <li>As we get older our bodies run on a colder temperature.</li>
                <li>So when you were 18, your baseline body temperature might have been 98.6, but today it might in fact be 97!</li>
                <li>So, what’s normal for one person could be signs of a fever in another person!</li>
                <li>So if someone with a baseline temperature of 97.7 measures in at 98.6, it could mean that <b>they’re not actually normal</b> - in fact they are starting to run a fever!</li>
                <li>
                    <label class="mb-1"><b>Does that make sense?</b></label>
                    <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                        <label class="my-0 mr-3 d-flex align-items-center">
                            <input type="radio" data-name="ans_baseline_expl_feedback_1" name="ans_baseline_expl_feedback_1" {{@$contentData['ans_baseline_expl_feedback_1'] && @$contentData['ans_baseline_expl_feedback_1'] === 'yes' ? 'checked' : ''}} value="yes">
                            <span class="ml-1">Yes</span>
                        </label>
                        <label class="my-0 mr-3 d-flex align-items-center">
                            <input type="radio" data-name="ans_baseline_expl_feedback_1" name="ans_baseline_expl_feedback_1" {{@$contentData['ans_baseline_expl_feedback_1'] && @$contentData['ans_baseline_expl_feedback_1'] === 'no' ? 'checked' : ''}} value="no">
                            <span class="ml-1">No</span>
                        </label>
                    </div>
                </li>
            </ul>
        </div>

        <div class="mb-2">
            <label class="mb-1"><b>So the numbers you read on self-monitoring equipment mean different things to different people.</b> So we’re going to go through your vital signs and each meter one by one, and I’m going to ask you some questions about each of them. <b>OK?</b></label>
            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_baseline_expl_feedback_2" name="ans_baseline_expl_feedback_2" {{@$contentData['ans_baseline_expl_feedback_2'] && @$contentData['ans_baseline_expl_feedback_2'] === 'yes' ? 'checked' : ''}} value="yes">
                    <span class="ml-1">Yes</span>
                </label>
                <label class="my-0 mr-3 d-flex align-items-center">
                    <input type="radio" data-name="ans_baseline_expl_feedback_2" name="ans_baseline_expl_feedback_2" {{@$contentData['ans_baseline_expl_feedback_2'] && @$contentData['ans_baseline_expl_feedback_2'] === 'no' ? 'checked' : ''}} value="no">
                    <span class="ml-1">No</span>
                </label>
            </div>
        </div>

        <hr class="my-3">

        <p><b>Temperature</b></p>

        <div class="ml-3">

            <div class="mb-2">
                <label class="mb-1">Do you know what your baseline temperature usually reads in at?</label>
                <input type="text" data-name="ans_baseline_temperature" value="{{@$contentData['ans_baseline_temperature']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
            </div>

            <div class="mb-2 ml-3">
                If you don't, don’t worry, we can measure that once you get the thermometer.
            </div>

            <div class="mb-2">
                <label class="mb-1">Do you currently feel like you may be running high?</label>
                <input type="text" data-name="ans_currently_running_high" value="{{@$contentData['ans_currently_running_high']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
            </div>

        </div>

        <hr class="my-3">

        <p><b>Blood Oxygen / Pulmonary</b></p>

        <div class="ml-3">

            <div class="mb-2">
                <label class="mb-1">And what about your baseline blood oxygen, do you know what that usually reads in at?</label>
                <input type="text" data-name="ans_baseline_blood_ox" value="{{@$contentData['ans_baseline_blood_ox']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
            </div>

            <div class="mb-2 ml-3">
                <ul>
                    <li>
                        <label class="mb-1">Have you ever operated a fingertip pulse oxygen meter by yourself?</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_blood_ox_by_self" name="ans_blood_ox_by_self" {{@$contentData['ans_blood_ox_by_self'] && @$contentData['ans_blood_ox_by_self'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_blood_ox_by_self" name="ans_blood_ox_by_self" {{@$contentData['ans_blood_ox_by_self'] && @$contentData['ans_blood_ox_by_self'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        Blood oxygen is particularly important to know about these days.
                        <ul>
                            <li>There are many causes of fever.</li>
                            <li>Most of them, like the normal flu, don’t affect your oxygen level.</li>
                            <li>COVID, however, almost always causes a drop in your oxygen level!</li>
                            <li>So, if you ever have a fever, and notice a drop in your blood oxygen level as well, it’s more likely to be COVID and you can help you seek appropriate medical attention sooner.</li>
                            <li>
                                <label class="mb-1">Does that make sense?</label>
                                <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                                    <label class="my-0 mr-3 d-flex align-items-center">
                                        <input type="radio" data-name="ans_blood_ox_expl_feedback" name="ans_blood_ox_expl_feedback" {{@$contentData['ans_blood_ox_expl_feedback'] && @$contentData['ans_blood_ox_expl_feedback'] === 'yes' ? 'checked' : ''}} value="yes">
                                        <span class="ml-1">Yes</span>
                                    </label>
                                    <label class="my-0 mr-3 d-flex align-items-center">
                                        <input type="radio" data-name="ans_blood_ox_expl_feedback" name="ans_blood_ox_expl_feedback" {{@$contentData['ans_blood_ox_expl_feedback'] && @$contentData['ans_blood_ox_expl_feedback'] === 'no' ? 'checked' : ''}} value="no">
                                        <span class="ml-1">No</span>
                                    </label>
                                </div>
                            </li>
                            <li>
                                Have you ever been diagnosed with any condition that affects the lungs and may possibly affect your blood oxygen readings, such as COVID, asthma, or COPD?
                                <ul>
                                    <li>
                                        <div>
                                            <label class="mb-1">COVID</label>
                                            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_covid" name="ans_blood_ox_condition_covid" {{@$contentData['ans_blood_ox_condition_covid'] && @$contentData['ans_blood_ox_condition_covid'] === 'yes' ? 'checked' : ''}} value="yes">
                                                    <span class="ml-1">Yes</span>
                                                </label>
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_covid" name="ans_blood_ox_condition_covid" {{@$contentData['ans_blood_ox_condition_covid'] && @$contentData['ans_blood_ox_condition_covid'] === 'no' ? 'checked' : ''}} value="no">
                                                    <span class="ml-1">No</span>
                                                </label>
                                            </div>
                                        </div>
                                        <ul>
                                            <li class="mb-2">
                                                <label class="mb-1">How are you feeling now?</label>
                                                <input type="text" data-name="ans_condition_covid_how_now" value="{{@$contentData['ans_condition_covid_how_now']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Have you recovered completely?</label>
                                                <input type="text" data-name="ans_condition_covid_recovered" value="{{@$contentData['ans_condition_covid_recovered']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Do you have any lingering symptoms like Shortness of breath, weakness, or brain fog?</label>
                                                <input type="text" data-name="ans_condition_covid_lingering_symptoms" value="{{@$contentData['ans_condition_covid_lingering_symptoms']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                        </ul>
                                    </li>
                                    <li>
                                        <div>
                                            <label class="mb-1">Asthma</label>
                                            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_asthma" name="ans_blood_ox_condition_asthma" {{@$contentData['ans_blood_ox_condition_asthma'] && @$contentData['ans_blood_ox_condition_asthma'] === 'yes' ? 'checked' : ''}} value="yes">
                                                    <span class="ml-1">Yes</span>
                                                </label>
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_asthma" name="ans_blood_ox_condition_asthma" {{@$contentData['ans_blood_ox_condition_asthma'] && @$contentData['ans_blood_ox_condition_asthma'] === 'no' ? 'checked' : ''}} value="no">
                                                    <span class="ml-1">No</span>
                                                </label>
                                            </div>
                                        </div>
                                        <ul>
                                            <li class="mb-2">
                                                <label class="mb-1">How are you feeling now?</label>
                                                <input type="text" data-name="ans_condition_asthma_how_now" value="{{@$contentData['ans_condition_asthma_how_now']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Have you recovered completely?</label>
                                                <input type="text" data-name="ans_condition_asthma_recovered" value="{{@$contentData['ans_condition_asthma_recovered']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Do you have any lingering symptoms like Shortness of breath, weakness, or brain fog?</label>
                                                <input type="text" data-name="ans_condition_asthma_lingering_symptoms" value="{{@$contentData['ans_condition_asthma_lingering_symptoms']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                        </ul>
                                    </li>
                                    <li>
                                        <div>
                                            <label class="mb-1">COPD</label>
                                            <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_copd" name="ans_blood_ox_condition_copd" {{@$contentData['ans_blood_ox_condition_copd'] && @$contentData['ans_blood_ox_condition_copd'] === 'yes' ? 'checked' : ''}} value="yes">
                                                    <span class="ml-1">Yes</span>
                                                </label>
                                                <label class="my-0 mr-3 d-flex align-items-center">
                                                    <input type="radio" data-name="ans_blood_ox_condition_copd" name="ans_blood_ox_condition_copd" {{@$contentData['ans_blood_ox_condition_copd'] && @$contentData['ans_blood_ox_condition_copd'] === 'no' ? 'checked' : ''}} value="no">
                                                    <span class="ml-1">No</span>
                                                </label>
                                            </div>
                                        </div>
                                        <ul>
                                            <li class="mb-2">
                                                <label class="mb-1">How are you feeling now?</label>
                                                <input type="text" data-name="ans_condition_copd_how_now" value="{{@$contentData['ans_condition_copd_how_now']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Have you recovered completely?</label>
                                                <input type="text" data-name="ans_condition_copd_recovered" value="{{@$contentData['ans_condition_copd_recovered']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Do you have any lingering symptoms like Shortness of breath, weakness, or brain fog?</label>
                                                <input type="text" data-name="ans_condition_copd_lingering_symptoms" value="{{@$contentData['ans_condition_copd_lingering_symptoms']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                        </ul>
                                    </li>
                                    <li>
                                        <div>
                                            <label class="mb-1">Other</label>
                                            <input type="text" data-name="ans_blood_ox_condition_other" value="{{@$contentData['ans_blood_ox_condition_other']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                        </div>
                                        <ul>
                                            <li class="mb-2">
                                                <label class="mb-1">How are you feeling now?</label>
                                                <input type="text" data-name="ans_condition_other_how_now" value="{{@$contentData['ans_condition_other_how_now']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Have you recovered completely?</label>
                                                <input type="text" data-name="ans_condition_other_recovered" value="{{@$contentData['ans_condition_other_recovered']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                            <li class="mb-2">
                                                <label class="mb-1">Do you have any lingering symptoms like Shortness of breath, weakness, or brain fog?</label>
                                                <input type="text" data-name="ans_condition_other_lingering_symptoms" value="{{@$contentData['ans_condition_other_lingering_symptoms']}}" class="form-control form-control-sm d-inline-block w-auto ml-2">
                                            </li>
                                        </ul>
                                    </li>
                                </ul>
                            </li>

                        </ul>
                    </li>
                </ul>
            </div>

        </div>

        <hr class="my-3">

        <p><b>Blood Oxygen / Pulmonary</b></p>

        <div class="ml-3">

            <div class="mb-2">
                <label class="mb-1">Do you know what your baseline heart rate and blood pressure usually read in at?</label>
                <div>
                    <input type="text" data-name="ans_baseline_heart_rate" value="{{@$contentData['ans_baseline_heart_rate']}}" placeholder="Heart Rate" class="form-control form-control-sm d-inline-block w-auto ml-2">
                    <input type="text" data-name="ans_baseline_bp" value="{{@$contentData['ans_baseline_bp']}}" placeholder="BP" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                </div>
            </div>

            <div class="mb-2">
                <label class="mb-1">Have you ever operated a digital blood pressure and pulse meter by yourself?</label>
                <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_bp_by_self" name="ans_bp_by_self" {{@$contentData['ans_bp_by_self'] && @$contentData['ans_bp_by_self'] === 'yes' ? 'checked' : ''}} value="yes">
                        <span class="ml-1">Yes</span>
                    </label>
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_bp_by_self" name="ans_bp_by_self" {{@$contentData['ans_bp_by_self'] && @$contentData['ans_bp_by_self'] === 'no' ? 'checked' : ''}} value="no">
                        <span class="ml-1">No</span>
                    </label>
                </div>
            </div>

            <div class="mb-2">
                <label class="mb-1">Have you ever been diagnosed with high blood pressure?</label>
                <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_high_bp_ever" name="ans_high_bp_ever" {{@$contentData['ans_high_bp_ever'] && @$contentData['ans_high_bp_ever'] === 'yes' ? 'checked' : ''}} value="yes">
                        <span class="ml-1">Yes</span>
                    </label>
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_high_bp_ever" name="ans_high_bp_ever" {{@$contentData['ans_high_bp_ever'] && @$contentData['ans_high_bp_ever'] === 'no' ? 'checked' : ''}} value="no">
                        <span class="ml-1">No</span>
                    </label>
                </div>
            </div>

            <div class="mb-2">
                <label class="mb-1">Do you take BP medicine?</label>
                <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_bp_medicine" name="ans_bp_medicine" {{@$contentData['ans_bp_medicine'] && @$contentData['ans_bp_medicine'] === 'yes' ? 'checked' : ''}} value="yes">
                        <span class="ml-1">Yes</span>
                    </label>
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_bp_medicine" name="ans_bp_medicine" {{@$contentData['ans_bp_medicine'] && @$contentData['ans_bp_medicine'] === 'no' ? 'checked' : ''}} value="no">
                        <span class="ml-1">No</span>
                    </label>
                </div>
            </div>

            <div class="mb-3 ml-3">
                <label class="mb-2">If taking BP medication:</label>
                <div class="mb-2">
                        <input type="text" data-name="ans_bp_medicine_1_type" value="{{@$contentData['ans_bp_medicine_1_type']}}" placeholder="Type" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                        <input type="text" data-name="ans_bp_medicine_1_dose" value="{{@$contentData['ans_bp_medicine_1_dose']}}" placeholder="Dose" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                </div>
                <div class="mb-2">
                        <input type="text" data-name="ans_bp_medicine_2_type" value="{{@$contentData['ans_bp_medicine_2_type']}}" placeholder="Type" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                        <input type="text" data-name="ans_bp_medicine_2_dose" value="{{@$contentData['ans_bp_medicine_2_dose']}}" placeholder="Dose" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                </div>
                <div class="mb-2">
                        <input type="text" data-name="ans_bp_medicine_3_type" value="{{@$contentData['ans_bp_medicine_3_type']}}" placeholder="Type" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                        <input type="text" data-name="ans_bp_medicine_3_dose" value="{{@$contentData['ans_bp_medicine_3_dose']}}" placeholder="Dose" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                </div>
            </div>

            <div class="mb-2">
                <label class="mb-1">Have you ever been diagnosed with any cardiac or heart condition that may affect your heart rate or blood pressure, such as....?</label>
                <ul>
                    <li>
                        <label class="mb-1">CAD or other atherosclerosis</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_cad" name="ans_cardiac_heart_ever_cad" {{@$contentData['ans_cardiac_heart_ever_cad'] && @$contentData['ans_cardiac_heart_ever_cad'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_cad" name="ans_cardiac_heart_ever_cad" {{@$contentData['ans_cardiac_heart_ever_cad'] && @$contentData['ans_cardiac_heart_ever_cad'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">Irregular heart rhythm</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_irr" name="ans_cardiac_heart_ever_irr" {{@$contentData['ans_cardiac_heart_ever_irr'] && @$contentData['ans_cardiac_heart_ever_irr'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_irr" name="ans_cardiac_heart_ever_irr" {{@$contentData['ans_cardiac_heart_ever_irr'] && @$contentData['ans_cardiac_heart_ever_irr'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">CHF</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_chf" name="ans_cardiac_heart_ever_chf" {{@$contentData['ans_cardiac_heart_ever_chf'] && @$contentData['ans_cardiac_heart_ever_chf'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_cardiac_heart_ever_chf" name="ans_cardiac_heart_ever_chf" {{@$contentData['ans_cardiac_heart_ever_chf'] && @$contentData['ans_cardiac_heart_ever_chf'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">Other</label>
                        <input type="text" data-name="ans_cardiac_heart_ever_other" value="{{@$contentData['ans_cardiac_heart_ever_other']}}" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                    </li>
                </ul>
            </div>

            <div class="mb-2">
                <label class="mb-1">Do you have any:</label>
                <ul>
                    <li>
                        <label class="mb-1">Chest pain</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_chest_pain" name="ans_chest_pain" {{@$contentData['ans_chest_pain'] && @$contentData['ans_chest_pain'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_chest_pain" name="ans_chest_pain" {{@$contentData['ans_chest_pain'] && @$contentData['ans_chest_pain'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">Shortness of breath?</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_shortness_of_breath" name="ans_shortness_of_breath" {{@$contentData['ans_shortness_of_breath'] && @$contentData['ans_shortness_of_breath'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_shortness_of_breath" name="ans_shortness_of_breath" {{@$contentData['ans_shortness_of_breath'] && @$contentData['ans_shortness_of_breath'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">Fatigue or light-headedness?</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_fatigue" name="ans_fatigue" {{@$contentData['ans_fatigue'] && @$contentData['ans_fatigue'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_fatigue" name="ans_fatigue" {{@$contentData['ans_fatigue'] && @$contentData['ans_fatigue'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                    <li>
                        <label class="mb-1">Headache?</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_headache" name="ans_headache" {{@$contentData['ans_headache'] && @$contentData['ans_headache'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_headache" name="ans_headache" {{@$contentData['ans_headache'] && @$contentData['ans_headache'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                </ul>
            </div>

            <div class="mb-2">
                <label class="mb-1">Do you ever notice an increase in your heart rate?</label>
                <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_increase_in_heart_rate" name="ans_increase_in_heart_rate" {{@$contentData['ans_increase_in_heart_rate'] && @$contentData['ans_increase_in_heart_rate'] === 'yes' ? 'checked' : ''}} value="yes">
                        <span class="ml-1">Yes</span>
                    </label>
                    <label class="my-0 mr-3 d-flex align-items-center">
                        <input type="radio" data-name="ans_increase_in_heart_rate" name="ans_increase_in_heart_rate" {{@$contentData['ans_increase_in_heart_rate'] && @$contentData['ans_increase_in_heart_rate'] === 'no' ? 'checked' : ''}} value="no">
                        <span class="ml-1">No</span>
                    </label>
                </div>
                <ul>
                    <li>
                        <label class="mb-1">How ofter?</label>
                        <input type="text" data-name="ans_increase_in_heart_rate_frequency" value="{{@$contentData['ans_increase_in_heart_rate_frequency']}}" class="ml-3 form-control form-control-sm d-inline-block w-auto ml-2">
                    </li>
                    <li>
                        <label class="mb-1">Do you monitor your BP before / after workouts?</label>
                        <div class="d-inline-flex ml-2 align-items-baseline pt-1">
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_monitor_bp_before_after_workouts" name="ans_monitor_bp_before_after_workouts" {{@$contentData['ans_monitor_bp_before_after_workouts'] && @$contentData['ans_monitor_bp_before_after_workouts'] === 'yes' ? 'checked' : ''}} value="yes">
                                <span class="ml-1">Yes</span>
                            </label>
                            <label class="my-0 mr-3 d-flex align-items-center">
                                <input type="radio" data-name="ans_monitor_bp_before_after_workouts" name="ans_monitor_bp_before_after_workouts" {{@$contentData['ans_monitor_bp_before_after_workouts'] && @$contentData['ans_monitor_bp_before_after_workouts'] === 'no' ? 'checked' : ''}} value="no">
                                <span class="ml-1">No</span>
                            </label>
                        </div>
                    </li>
                </ul>
            </div>

        </div>

        <hr class="my-3">

	    <div class="ml-3 mb-3">
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_cdc_push" {{@$contentData['ans_vaccine_push'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">Educated patient that self-monitoring is not a replacement for following CDC guidelines re: vaccines, mask-wearing, and social distancing; <strong>CDC guidelines re: vaccines, masks, and social distancing are the most effective strategy to reduce COVID-19 risk.</strong>.</span>
            </label>
        </div>
        
	    <p><b>Vaccine Status:</b></p>

        <div class="ml-3 mb-3">
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_vaccine_status_declined_to_answer" {{@$contentData['ans_vaccine_status_declined_to_answer'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">Declined to answer</span>
            </label>
            <div>
                Status: <input type="text" data-name="ans_vaccine_status" value="{{@$contentData['ans_vaccine_status']}}" class="form-control form-control-sm d-inline-block w-auto">
            </div>
            <div class="mt-2">
                Support needed? <input type="text" data-name="ans_vaccine_status" value="{{@$contentData['ans_vaccine_status']}}" class="form-control form-control-sm d-inline-block w-auto">
            </div>
        </div>

        <p><b>Booster Status:</b></p>

        <div class="ml-3 mb-3">
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_booster_status_declined_to_answer" {{@$contentData['ans_booster_status_declined_to_answer'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">Declined to answer</span>
            </label>
            <div>
                Status: <input type="text" data-name="ans_booster_status" value="{{@$contentData['ans_booster_status']}}" class="form-control form-control-sm d-inline-block w-auto">
            </div>
            <div class="mt-2">
                Support needed? <input type="text" data-name="ans_vaccine_status" value="{{@$contentData['ans_vaccine_status']}}" class="form-control form-control-sm d-inline-block w-auto">
            </div>
        </div>

        <div class="mb-3">
            <label class="mb-1"><strong>Current Behaviors to Stay Safe:</strong></label>
            <input type="text" data-name="ans_current_behaviors_to_stay_safe" value="{{@$contentData['ans_current_behaviors_to_stay_safe']}}" class="form-control form-control-sm">
            <div class="mt-2">
                Support needed? <input type="text" data-name="ans_vaccine_status" value="{{@$contentData['ans_vaccine_status']}}" class="form-control form-control-sm d-inline-block w-auto">
            </div>
        </div>

        <p><b>Education Provided:</b></p>

        <div class="ml-3 mb-3">
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_edu_provided_use_of_smd" {{@$contentData['ans_edu_provided_use_of_smd'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">Appropriate use of self-monitoring devices</span>
            </label>
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_edu_provided_asymptomatic_hypoxia" {{@$contentData['ans_edu_provided_asymptomatic_hypoxia'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">Asymptomatic hypoxia</span>
            </label>
            <label class="mb-2 d-flex align-items-center">
                <input type="checkbox" data-name="ans_edu_provided_cdc_guidelines" {{@$contentData['ans_edu_provided_cdc_guidelines'] ? 'checked' : ''}} class="mr-2">
                <span class="ml-2">CDC guidelines</span>
            </label>
        </div>

	    <p><b>Printed material to be sent:</b></p>
        <div class="ml-3 mb-3">
            <label class="mb-2 d-flex align-items-center">
                    <input type="checkbox" data-name="ans_cdc_guidelines_aarp_mental_health" {{@$contentData['ans_cdc_guidelines_aarp_mental_health'] ? 'checked' : ''}} class="mr-2">
                    <span class="ml-2">CDC "How to Protect Yourself & Others" & AARP mental health / COVID alert</span>
                </label>
            <label class="mb-2 d-flex align-items-center">
                    <input type="checkbox" data-name="ans_follow_up_scheduled" {{@$contentData['ans_follow_up_scheduled'] ? 'checked' : ''}} class="mr-2">
                    <span class="ml-2">Follow-up scheduled</span>
                </label>
        </div>

        <div class="mb-2">
            <label class="mb-1"><b>Total minutes  spent on this visit counseling or educating a patient or caregiver, documentation, and care coordination.</b></label>
            <input type="text" data-name="ans_total_mins_spent" value="{{@$contentData['ans_total_mins_spent']}}" class="form-control form-control-sm">
            <small class="d-none">Over 50% of this time was directed towards counseling and education.</small>
        </div>

        <div class="mb-3">
            <label class="mb-1">Remarks</label>
            <textarea data-name="remarks" class="form-control form-control-sm" rows="2">{{ @$contentData['remarks'] }}</textarea>
        </div>

        <div class="pt-2">
            <button submit class="btn btn-sm btn-primary mr-2"><i class="fa fa-save"></i></button>
            <div class="d-inline-flex align-self-stretch align-items-center">
                <span class="autosave-indicator saving text-sm text-secondary">Saving changes &hellip;</span>
                <span class="autosave-indicator saved text-sm text-secondary">
                    <i class="fa fa-check"></i>
                    Saved
                </span>
            </div>
        </div>
    </form>
</div>
<script>
    (function() {
        function init() {
            $('div[moe] form:not([show])').hide();
            // if in popup (omega template), add provision to toggle relevance
            @include('app.patient.segment-templates._common_actions.toggle-relevance', ['container' => '#edit-module-covid-intake'])
        }
        addMCInitializer('edit-module-covid-intake-{{$note->id}}', init, '#edit-module-covid-intake');
    }).call(window);
</script>
