<div class="page-content-wrapper">
    <div class="page-content">
        <div class="row">
            <div class="col-md-12">
                <!-- BEGIN EXAMPLE TABLE PORTLET-->
                <div class="portlet box blue">
                    <div class="portlet-title">
                        <div class="caption">
                            <i class="fa fa-user"></i>Hystroscopic
                        </div>
                    </div>
                    <div class="portlet-body">

                        <!--Begin Semen-->

                        <div class="row">

                            <div class="portlet-title tbox">
                                <div class="caption font-blue-haze col-md-6">
                                    <span class="caption-subject bold uppercase">Add new </span>
                                </div>

                            </div>

                            <div class="clearfix"></div>

                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=hystroscopicAdd" class="clinick awval" method="post">
                                <h5 class="note bg-green-jungle text-right"><strong>&lt;br&gt;</strong>  فى حالة الرغبة لنزول سطر جديد يرجى وضع هذا الكود  </h5>
                                <input type="hidden" id="patientId" name="patientId" value="{$patientId}"/>

                                <div class="form-body row">


                                    <div class="col-md-3">
                                        <div class="form-group">
                                            <label class="col-md-12 control-label">Date:</label>
                                            <div class="col-md-12">
                                                <input type="text" class="form-control datepicker" required="required" value="{'today'|date_format:'Y-m-d'}" name="created_at" readonly/>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-2">
                                        <div class="form-group">
                                            <label class="col-md-12 control-label">Templates:</label>
                                            <div class="col-md-12">
                                                <select class="form-control select2me" id="hystroscopic_template" required="required" name="template_id" data-placeholder="Select...">
                                                    <option></option>
                                                    {foreach  $hystroscopic as $single}
                                                    <option value="{$single->id}">{$single->template_name}</option>
                                                    {/foreach}
                                                </select>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-3">
                                        <div class="form-group">
                                            <label class="col-md-12 control-label">Diagnosis:</label>
                                            <div class="col-md-12">
                                                <select multiple="" size="1" name="diagnosis[]" class="form-control select2me diagnosis">
                                                    {foreach $allDiagnosis as $data}
                                                    <option value="{$data->id}">{$data->name}</option>
                                                    {/foreach}
                                                </select>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-4">
                                        <div class="form-group">
                                            <label class="col-md-12 control-label">Diagnosis:</label>
                                            <div class="col-md-12">
                                                <input type="text" class="form-control" value="" name="diagnosis_text"/>
                                            </div>
                                        </div>
                                    </div>


                                    <div class="clearfix" style="margin-bottom: 20px;"></div>

                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Entry</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="entry" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="entry_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>

                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">External Os.</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="external_os" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="external_os_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Cervical Canal</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="cervical_canal" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="cervical_canal_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Internal Os</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="internal_os" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="internal_os_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Uterine Cavity</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="uterine_cavity" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="uterine_cavity_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Endometrium</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="endometrium" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="endometrium_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Right Ostium</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="right_ostium" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="right_ostium_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Left Ostium</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="left_ostium" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="left_ostium_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Other</label>
                                        <div class="col-md-5">
                                            <input class="form-control" name="other" placeholder="Findings" type="text">
                                        </div>
                                        <div class="col-md-5">
                                            <input class="form-control" name="other_procedures" placeholder="Procedures" type="text">
                                        </div>
                                    </div>
                                    <div class="form-group ">
                                        <label class="col-md-2 txtl">Recommendations</label>
                                        <div class="col-md-10">
                                            <textarea class="form-control" name="recommendations" rows="4"></textarea>
                                        </div>
                                    </div>

                                </div>

                                <div class="form-actions">
                                    <div class="row">
                                        <div class="col-md-offset-2 col-md-10">
                                            <a class="btn default" href="{$hosturl}/controllers/{$controllname}.php?ac=index&patientid={$patientId}">Cancel</a>
                                            <button class="btn blue" type="submit">Submit</button>

                                        </div>
                                    </div>
                                </div>
                            </form>

                        </div>
                    </div>
                </div>
            </div>

        </div>
    </div>
</div>


