{% extends 'base.html.twig' %}

{% block title %}Add Delivery Details{% endblock %}

{% block content %}
	<div class="kt-subheader kt-grid__item"></div>

	{{ form_start(form, { 'attr': { 'class': 'kt-form' }}) }}
		<div class="kt-container kt-grid__item kt-grid__item--fluid">
			<div class="kt-portlet kt-portlet--mobile" id="kt_page_portlet">
				<div class="kt-portlet__head kt-portlet__head--lg">
					<div class="kt-portlet__head-label">
						<h3 class="kt-portlet__head-title">Add Delivery Details</h3>
					</div>

					<div class="kt-portlet__head-toolbar">
						<div class="kt-portlet__head-wrapper">
							<a href="{{ path('woman_care_index') }}" class="btn btn-clean btn-icon-sm mr-2"><i class="la la-long-arrow-left"></i>Back</a>
							<a href="{{ app.request.uri }}" class="btn btn-secondary btn-bold mr-2">Reset</a>
							<button class="btn btn-primary btn-bold">Submit</button>
						</div>
					</div>
				</div>

				<div class="kt-portlet__body">
					<div class="row">
						<div class="col-4">
							<div class="form-group row">
								{{ form_label(form.bpSystolic, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="input-group">
                    <div class="input-group-prepend">
                      <span class="input-group-text">Systolic</span>
                    </div>

										{{ form_widget(form.bpSystolic, {'attr': { 'class': 'form-control','maxlength':'4', 'oninput':"this.value = this.value.replace(/[^0-9]/g, '')"}}) }}

                    <div class="input-group-prepend">
                      <span class="input-group-text">Diastolic</span>
                    </div>

										{{ form_widget(form.bpDiastolic, {'attr': { 'class': 'form-control', 'maxlength':'4', 'oninput':"this.value = this.value.replace(/[^0-9]/g, '')" }}) }}
									</div>

									{{ form_errors(form.bpSystolic) }}
									{{ form_errors(form.bpDiastolic) }}
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.babyTemp, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="input-group">
										{{ form_widget(form.babyTemp, {'attr': { 'class': 'form-control', 'maxlength':'4', 'oninput':"this.value = this.value.replace(/[^0-9]/g, '')" }}) }}

                    <div class="input-group-append">
                      <span class="input-group-text">&deg;F</span>
                    </div>

										{{ form_errors(form.babyTemp) }}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.uterusPos, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="kt-radio-inline">
										{% for child in form.uterusPos %}
											<label class="kt-radio kt-radio--bold kt-radio--brand">
												{{ form_widget(child, {'attr': { 'class': 'kt-radio' }}) }}
												{{ form_label(child, null, { 'label_attr': { 'class': 'non-req' }}) }}
												{{ form_errors(child) }}
												<span></span>
											</label>
										{% endfor %}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.nipplePos, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="kt-radio-inline">
										{% for child in form.nipplePos %}
											<label class="kt-radio kt-radio--bold kt-radio--brand">
												{{ form_widget(child, {'attr': { 'class': 'kt-radio' }}) }}
												{{ form_label(child, null, { 'label_attr': { 'class': 'non-req' }}) }}
												{{ form_errors(child) }}
												<span></span>
											</label>
										{% endfor %}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.dangerSign, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									{{ form_widget(form.dangerSign, {'attr': { 'class': 'form-control select-picker' }}) }}
									{{ form_errors(form.dangerSign) }}
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.deliveryType, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									{{ form_widget(form.deliveryType, {'attr': { 'class': 'form-control select-picker' }}) }}
									{{ form_errors(form.deliveryType) }}
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.babyGender, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="kt-radio-inline">
										{% for child in form.babyGender %}
											<label class="kt-radio kt-radio--bold kt-radio--brand">
												{{ form_widget(child, {'attr': { 'class': 'kt-radio' }}) }}
												{{ form_label(child, null, { 'label_attr': { 'class': 'non-req' }}) }}
												{{ form_errors(child) }}
												<span></span>
											</label>
										{% endfor %}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.babyStatus, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									{{ form_widget(form.babyStatus, {'attr': { 'class': 'form-control select-picker' }}) }}
									{{ form_errors(form.babyStatus) }}
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.babyWeight, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<div class="input-group">
										{{ form_widget(form.babyWeight, {'attr': { 'class': 'form-control', 'maxlength':'3', 'oninput':"this.value = this.value.replace(/[^0-9]/g, '')" }}) }}

                    <div class="input-group-append">
                      <span class="input-group-text">in KG</span>
                    </div>

										{{ form_errors(form.babyWeight) }}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isAbortion, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isAbortion) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isCriedAfterBirth, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isCriedAfterBirth) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isPassedStool, '', {'label_attr': { 'class': 'col-4 col-form-label font-weight-bold' }}) }}

								<div class="col-8">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isPassedStool) }}
										<span></span>
									</label>
								</div>
							</div>
						</div>

						<div class="col-4">
							<div class="form-group row">
								{{ form_label(form.isDiarrhea, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isDiarrhea) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isPnemonia, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isPnemonia) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isPreterm, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isPreterm) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isAsphaxia, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isAsphaxia) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isMalaria, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isMalaria) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isCongenitalDetected, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isCongenitalDetected) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isInjury, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isInjury) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isMr, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isMr) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isNcd, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isNcd) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isVomitting, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isVomitting) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isActiveness, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isActiveness) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.respiration, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<div class="kt-radio-inline">
										{% for child in form.respiration %}
											<label class="kt-radio kt-radio--bold kt-radio--brand">
												{{ form_widget(child, {'attr': { 'class': 'kt-radio' }}) }}
												{{ form_label(child, null, { 'label_attr': { 'class': 'non-req' }}) }}
												{{ form_errors(child) }}
												<span></span>
											</label>
										{% endfor %}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isDiptheria, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isDiptheria) }}
										<span></span>
									</label>
								</div>
							</div>
						</div>

						<div class="col-4">
							<div class="form-group row">
								{{ form_label(form.isTetanus, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isTetanus) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isPertusis, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isPertusis) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isMeningitis, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isMeningitis) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isAids, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isAids) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isConvulsions, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isConvulsions) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isBreastSuckling, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isBreastSuckling) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isChestInSide, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isChestInSide) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isJaundice, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isJaundice) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.umbilicalCord, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<div class="kt-radio-inline">
										{% for child in form.umbilicalCord %}
											<label class="kt-radio kt-radio--bold kt-radio--brand">
												{{ form_widget(child, {'attr': { 'class': 'kt-radio' }}) }}
												{{ form_label(child, null, { 'label_attr': { 'class': 'non-req' }}) }}
												{{ form_errors(child) }}
												<span></span>
											</label>
										{% endfor %}
									</div>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isSepsis, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isSepsis) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.otherComplications, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									{{ form_widget(form.otherComplications, {'attr': { 'class': 'form-control', 'maxlength':'255' }}) }}
									{{ form_errors(form.otherComplications) }}
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.isBathAfterBirth, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									<label class="kt-checkbox col-1 kt-checkbox--bold kt-checkbox--brand">
										{{ form_widget(form.isBathAfterBirth) }}
										<span></span>
									</label>
								</div>
							</div>

							<div class="form-group row">
								{{ form_label(form.remarks, '', {'label_attr': { 'class': 'col-5 col-form-label font-weight-bold' }}) }}

								<div class="col-7">
									{{ form_widget(form.remarks, {'attr': { 'class': 'form-control','maxlength':'10', 'onkeydown':"return /[0-9a-zA-Z ]/i.test(event.key)" }}) }}
									{{ form_errors(form.remarks) }}
								</div>
							</div>
						</div>
					</div>
	    	</div>
	  	</div>
	  </div>
  {{ form_end(form) }}
{% endblock %}

{% block scripts %}
	{{ parent() }}

	<script>
		$('.select-picker').selectpicker();
	</script>
{% endblock %}