@extends( 'layouts.master' )

@section( 'style' )

@parent

@endsection

@section( 'content' )

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

<tr>
	<td>			  
		<h2>Report Adverse Event Online</h2>
		<h3>Step 1 of 3: General Information</h3>
		<label><span class="reqIndicator">*</span> = required field&nbsp;</label>
		
		<form id="form_report" role="form" method="POST" action="{{ url( '/report' ) }}">
			{!! csrf_field() !!}

			<fieldset>				
				<div class="report_item">
					<label >Case Number:</label>
					<label><strong>{{ $case->id }}</strong></label>
				</div>
				
				<fieldset>
					<legend>Reporter</legend>
					@include( 'includes.form.text', [
						'require' => true,
						'label' => 'Age:',
						'labelPrefix' => '&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;',
						'name' => 'reporter[age]',
						'oldName' => 'reporter.age',
						'sessionValue' => $case->reporter->age,
					] )
					
					@include( 'includes.form.radio', [
						'require' => true,
						'label' => 'Role:',
						'labelPrefix' => '&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;',
						'name' => 'reporter[role]',
						'oldName' => 'reporter.role',
						'sessionValue' => $case->reporter->role,
						'options' => [
							'physician' => 'Physician',
							'other' => 'Other',
						],
					] )
					
					@include( 'includes.form.radio', [
						'require' => true,
						'label' => 'Gender:',
						'labelPrefix' => '&nbsp;',
						'name' => 'reporter[gender]',
						'oldName' => 'reporter.gender',
						'sessionValue' => $case->reporter->gender,
						'options' => [
							'male' => 'Male',
							'female' => 'Female',
						],
					] )
					
					<!-- TODO
					<div class="report_item">
						<label>&nbsp; &nbsp;&nbsp; &nbsp;&nbsp; &nbsp;Relation with Patient:</label>
						<select name="relation" id="relation">
							<option value=""  selected="selected" ></option>
							<option value="Patient"  selected="selected" >Patient</option>
							<option value="Sibling"  selected="selected" >Sibling</option>
					</select>
					</div>
					 -->
				</fieldset>
			</fieldset>
			
			<br />
			
			<!-- <input name="submit" type="submit" value="Save and Continue"/> -->
			
			<input type="hidden" name="step" value="{{ $case->step }}"/>
			
			<button type="reset">Reset</button>
			
			<button type="submit" name="action" value="save">Save</button>
			
			<button type="submit" name="action" value="save_continue">Save and Continue</button>
		</form>	
	</td>
</tr>

</table>

@endsection