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@@ -1,13 +1,53 @@
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<?php
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+$fields = [
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+ [
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+ "Head:::Trauma",
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+ "Eyes:::Blindness|Cataracts|Glaucoma|Wears glasses/contacts",
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+ "Ears:::Hearing aids",
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+ "Nose/Sinuses:::Allergic Rhinitis|Sinus infections",
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+ "Mouth/Throat/Teeth:::Dentures",
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+ "Cardiovascular:::Aneurysm|Angina|DVT|Dysrhythmia|HTN|Murmur|Myocardial infarction|Other heart disease",
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+ ],
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+ [
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+ "Respiratory:::Asthma|Bronchitis|COPD - Bronchitis/Emphysema|Pleuritis|Pneumonia",
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+ "Gastrointestinal:::Cirrhosis|GERD|Gallbladder disease|Heartburn|Hemorrhoids|Hepatitis|Hiatal hernia|Jaundice|Ulcer",
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+ "Genitourinary:::Hernia|Incontinence|Nephrolithiasis|Other kidney disease|STDs|UTI(s)",
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+ ],
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+ [
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+ "Musculoskeletal:::Arthritis|Gout|M/S injury",
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+ "Skin:::Dermatitis|Mole(s)|Other skin condition(s)|Psoriasis",
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+ "Neurological:::Epilepsy|Seizures|Severe headaches, migraines|Stroke|TIA",
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+ "Psychiatric:::Bipolar disorder|Depression|Hallucinations, delusions|Suicidal ideation|Suicide attempts",
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+ ],
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+ [
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+ "Endocrine:::Goiter|Hyperlipidemia|Hypothyroidism|Thyroid disease|Thyroiditis|Type I DM|Type II DM",
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+ "Heme/Onc:::Anemia|Cancer",
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+ "Infectious:::HIV|STDs|Tuberculosis (dz)|Tuberculosis (exposure)",
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+ ]
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+];
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+
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$contentData = false;
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if($section){
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$contentData = json_decode($section->content_data, true);
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}
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-if(!$contentData || !isset($contentData['value'])) {
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- $contentData = [
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- 'value'=>''
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- ];
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+if(!$contentData) {
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+ $contentData = [];
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}
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+for ($i = 0; $i < count($fields); $i++) {
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+ for($j = 0; $j < count($fields[$i]); $j++) {
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+ $parts = explode(":::", $fields[$i][$j]);
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+ $head = 'custom';
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+ if(!empty($parts[0])) $head = $parts[0];
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+ $values = explode("|", $parts[1]);
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+ for($k = 0; $k < count($values); $k++) {
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+ $fName = $head . '_' . $values[$k];
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+ if(!isset($contentData[$fName])) {
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+ $contentData[$fName] = '';
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+ }
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+ }
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+ }
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+}
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+
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$formID = rand(0, 100000);
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?>
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<form method="POST" action="/process_form_submit" onsubmit="return submitForm_NoteSection_{{ $formID }}(this);">
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@@ -17,9 +57,45 @@ $formID = rand(0, 100000);
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<input type="hidden" name="note_uid" value="<?= $note->uid?>">
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<input type="hidden" name="section_template_uid" value="<?= $sectionTemplate->uid ?>">
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<?php endif; ?>
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- <div class="form-group mb-2">
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- <textarea rte type="text" class="form-control form-control-sm p-2" name="value" placeholder="Value"><?= $contentData['value'] ?></textarea>
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+
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+ <div class="row">
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+ @for ($i = 0; $i < count($fields); $i++)
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+ <div class="col-md-3">
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+ @for($j = 0; $j < count($fields[$i]); $j++)
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+ <?php
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+ $parts = explode(":::", $fields[$i][$j]);
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+ $head = 'custom';
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+ if(!empty($parts[0])) $head = $parts[0];
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+ $values = explode("|", $parts[1]);
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+ ?>
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+ <div class="mb-3">
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+ @if($head !== 'custom')
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+ <div class="font-weight-bold mb-2">{{ $head }}</div>
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+ @endif
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+ @for($k = 0; $k < count($values); $k++)
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+ <?php
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+ $fName = $head . '_' . $values[$k];
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+ ?>
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+ <label class="d-flex align-items-center mb-1">
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+ <input type="checkbox" name="{{ $fName }}" {{ $contentData[$fName] ? 'checked' : '' }} class="m-0">
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+ <span class="ml-2">{{ $values[$k] }}</span>
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+ </label>
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+ @endfor
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+ </div>
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+ @endfor
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+ </div>
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+ @endfor
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+ </div>
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+
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+ <div class="row mb-3">
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+ <div class="col-12">
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+ <textarea rte type="text" class="form-control form-control-sm p-2"
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+ name="comments"
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+ data-shortcuts="{{ $shortcuts }}"
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+ placeholder="Value"><?= isset($contentData['comments']) ? $contentData['comments'] : '' ?></textarea>
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+ </div>
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</div>
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+
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<div class="form-group m-0 d-flex">
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<button class="btn btn-sm btn-primary mr-2">Submit</button>
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<button class="btn btn-sm btn-default border" onclick="return cancelForm_NoteSection_{{ $formID }}(this)">Cancel</button>
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