@extends( 'layouts.master' )

@section( 'style' )

@parent

<style>
td.field-label-1{
	width : 30%;
}

td.field-label-2{
	width : 50%;
}



td.field-value {
	width: 50%;
	background-color : #D3D3D3;
}

a.edit {
	border : 1px solid black;
	font-size : 12px;
	font-weight : bold;
	padding-top : 3px;
	padding-bottom : 3px;
	background-color : buttonface;
}
</style>

@endsection

@section( 'content' )

<table width="850" align="center">

<tr>
	<td>
		<h2>Step 4 of 4: Review Submission</h2>
		<label><span class="reqIndicator">*</span> = required field&nbsp;</label>
	</td>
</tr>

<tr>
	<td>
		<form id="form_report" role="form" method="POST" action="{{ url( '/report' ) }}">
			{!! csrf_field() !!}
			
			<h3>Step 1: General Information&nbsp;&nbsp;&nbsp;<a class="button edit" href="{{ url( 'report/1' ) }}"">Edit</a></h3>
			
			<table class="summary" align="center" width="75%" border="1" cellpadding="4" cellspacing="1">
			
			<tr>
				<td colspan="3">
					<label><strong>Reporter Information<strong></label>
				</td>
			</tr>
			
			<tr>
				<td class="field-label-2" colspan="2">
					<label><span class="reqIndicator">*</span>Report Age:</label>
				</td>
				<td class="field-value">
					<label>{{ $case->reporter->age }}</label>
				</td>
			</tr>
			<tr>
				<td class="field-label-2" colspan="2">
					<label><span class="reqIndicator">*</span>Report Role:</label>
				</td>
				<td class="field-value" colspan="2">
					<label>{{ $case->reporter->role }}</label>
				</td>
			</tr>
			<tr>
				<td class="field-label-2" colspan="2">
					<label><span class="reqIndicator">*</span>Report Gender:</label>
				</td>
				<td class="field-value">
					<label>{{ $case->reporter->gender }}</label>
				</td>
			</tr>
			
			</table>
		</td>
		
	</tr>
	
	<tr>
		<td>
			<h3>Step 2: Vaccine Administrative Information&nbsp;&nbsp;&nbsp;<a class="button edit" href="{{ url( 'report/2' ) }}"">Edit</a></h3>
			
			<table class="summary" align="center" width="75%" border="1" cellpadding="4" cellspacing="1">
			
			@foreach( $case->admin as $adminIndex => $admin )
			
				<tr>
					<td colspan="3" style="max-width: 20%">
						<label><strong>Vaccine Administration #{{ $adminIndex + 1 }}<strong></label>
					</td>
				</tr>
			
				@foreach( $admin->vaccine as $vaccineIndex => $vaccine )
					<td rowspan="7">
						<label><span class="reqIndicator">*</span><strong>Vaccine #{{ $vaccineIndex + 1 }}</strong></label>
					</td>
					<tr>
						<td class="field-label-1">
							<label>Name:</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->label }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>Manufacturer (Brand):</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->manufacturer }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>Lot Number:</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->lot_number }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>Route:</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->route }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>Site:</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->site }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>No. of Previous Doses:</label>
						</td>
						<td class="field-value">
							<label>{{ $vaccine->previous_dose }}</label>
						</td>
					</tr>
				@endforeach
				<tr>
					<td class="field-label-2" colspan="2">
						<label><span class="reqIndicator">*</span>Date Vaccine Administered (mm/dd/yyyy):</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->date }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Time Vaccine Administered (eg. AM, 6:15 PM):</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->time }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Vaccinated At:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->location }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Vaccine Purchased With:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->purchase }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Any Illnesses at Time of Vaccination?:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->illness }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Pre-existing Physician-Diagnosed Allergies, Birth Defects, Medical Conditions at Time of Vaccination:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->previous_illness }}</label>
					</td>
				</tr>
				
				<td rowspan="4">
					<label><strong>Vaccine Administrator</strong></label>
				</td>
				<tr>
					<td class="field-label-1">
						<label>First Name:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->admin_first_name }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Last Name:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->admin_first_name }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>MI:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->admin_middle_name }}</label>
					</td>
				</tr>
				
				<td rowspan="4">
					<label><strong>Responsible Physician</strong></label>
				</td>
				<tr>
					<td class="field-label-1">
						<label>First Name:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->physician_first_name }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Last Name:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->physician_first_name }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>MI:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->physician_middle_name }}</label>
					</td>
				</tr>
				
				<td rowspan="9">
					<label><strong>Facility</strong></label>
				</td>
				<tr>
					<td class="field-label-1">
						<label>Facility Name:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_name }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Address:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_address_1 }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Address 2:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_address_2 }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>City:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_city }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>State:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_state }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Country:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_country }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Postal Code:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_zip }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-1">
						<label>Phone:</label>
					</td>
					<td class="field-value">
						<label>{{ $admin->facility_phone }}</label>
					</td>
				</tr>
			@endforeach
			
			</table>
		</td>
	</tr>
	
	<tr>
		<td>
			<h3>Step 3: Adverse Event & Event Outcomes&nbsp;&nbsp;&nbsp;<a class="button edit" href="{{ url( 'report/3' ) }}"">Edit</a></h3>
			
			<table class="summary" align="center" width="75%" border="1" cellpadding="4" cellspacing="1">
				@foreach( $case->event->adverse as $adverseIndex => $adverse )
					<td rowspan="3">
						<label><span class="reqIndicator">*</span><strong>Adverse Event #{{ $adverseIndex + 1 }}</strong></label>
					</td>
					<tr>
						<td class="field-label-1">
							<label>Adverse Event Name:</label>
						</td>
						<td class="field-value">
							<label>{{ $adverse->label }}</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-1">
							<label>Comment:</label>
						</td>
						<td class="field-value">
							<label>{{ $adverse->comment }}</label>
						</td>
					</tr>
				@endforeach
				
				@if($case->event->death == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Patient Died?</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Patient Death Date:</label>
						</td>
						<td class="field-value">
							<label>{{ $case->event->death_date }}</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->life_threaten_ill == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Life Threatening Illness?</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->emergency_visit == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Required Emergency Room/Doctor Visit</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->hospital == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Required Hospitalization?</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Hospitalization Days:</label>
						</td>
						<td class="field-value">
							<label>{{ $case->event->hospital_days }}</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->hospital_prolong == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Resulted in Prolongation of Hospitilization?</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->disability == 'on' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Resulted in Permanent Disability?</label>
						</td>
						<td class="field-value">
							<label>yes</label>
						</td>
					</tr>
				@endif
				
				@if($case->event->recover != '' )
					<tr>
						<td class="field-label-2" colspan="2">
							<label>Patient Recovered?</label>
						</td>
						<td class="field-value">
							<label>{{ $case->event->recover }}</label>
						</td>
					</tr>
				@endif
				
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Adverse Event Onset Date (mm/dd/yyyy):</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->onset_date }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Adverse Event Onset Time (eg. AM, 6:15 PM):</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->onset_time }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Relevant Diagnostic Tests & Laboratory Data:</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->lab_test }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Other Medications:</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->other_medication }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Immunization Project Report Number:</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->report_number }}</label>
					</td>
				</tr>
				<tr>
					<td class="field-label-2" colspan="2">
						<label>Date Received by Immunization Project (mm/dd/yyyy):</label>
					</td>
					<td class="field-value">
						<label>{{ $case->event->report_date }}</label>
					</td>
				</tr>
			</table>
			
			<br />
			
			<div align="center">
				<input type="hidden" name="step" value="{{ $case->step }}"/>
				
				<button type="submit" name="action" value="submit" style="font-size: 20px">Submit</button>
			</div>
		</form>
	</td>
</tr>

</table>

@endsection