
<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>Sperm Freezing Report
                        </div>
                        <div class="actions">

                            {if $patientId}

                            <a href="{$hosturl}/controllers/{$controllname}.php?ac=show&&patientid={$patientId}" class="btn btn-default btn-sm">
                                Show Reports  </a>
                            {else}
                            <a href="{$hosturl}/controllers/{$controllname}.php?ac=show" class="btn btn-default btn-sm">
                                Show Reports </a>
                            {/if}

                        </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</span>
                                </div>

                            </div>

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

                            {if $patientId}
                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=addit&patientid={$patientId}" method="post" class="clinick">
                                {else}
                                <form action="{$hosturl}/controllers/{$controllname}.php?ac=addit" method="post" class="clinick">
                                    {/if}
                                    <div class="form-body">


                                        <div class="form-group ">
                                            <label class="col-md-2 txtl" for="form_control_1">Ref. by Prof. Dr :</label>
                                            <div class="col-md-5">
                                                <select class="form-control" id="ref_by_dr_id" name="ref_by_dr_id" data-colName="name" select-tableName="awusers"  data-id="{$one.user_id}" >
                                                    <option value="">choose</option>
                                                    {foreach  $users as $one}
                                                    <option value="{$one.user_id}">{$one.name}</option>
                                                    {/foreach}

                                                </select>

                                            </div>
                                        </div>
                                        <div class="form-group ">
                                            <div class="col-md-6">
                                                <label class="col-md-4 control-label" for="form_control_1">
                                                    Sperm Source
                                                </label>
                                                <div class="col-md-8">

                                                    <div class="col-md-5">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio"  id="Ejaculate" name="sperm_source" class="md-radiobtn sradio" data-val="0">
                                                                <label for="Ejaculate">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    Ejaculate </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-5">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio"  id="Aspiration" name="sperm_source" class="md-radiobtn sradio" data-val="1">
                                                                <label for="Aspiration">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    Test. Aspiration </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-5">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio" id="EpidAspiration" name="sperm_source" class="md-radiobtn sradio" data-val="2">
                                                                <label for="EpidAspiration">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    Epid. Aspiration </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-5">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio" id="TestBiopsy" name="sperm_source" class="md-radiobtn sradio" data-val="3">
                                                                <label for="TestBiopsy">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    Test. Biopsy </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group ">
                                            <div class="col-md-12">
                                                <label class="col-md-2 control-label" for="form_control_1">
                                                    Sperm Parameters
                                                </label>
                                                <div class="col-md-8">
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Count:
                                                        </label>
                                                        <div class="col-md-4">
                                                            <input type="text" name="count" class="form-control input-sm " id="form_control_1" placeholder="" >
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Motility:
                                                        </label>
                                                        <div class="col-md-4">
                                                            <input type="text" name="motility" class="form-control input-sm " id="form_control_1" placeholder="">
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            (A+B):
                                                        </label>
                                                        <div class="col-md-4">
                                                            <input type="text" name="a_plus_b" class="form-control input-sm updateElement" id="form_control_1" placeholder="" >
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Morphology(Abn.):
                                                        </label>
                                                        <div class="col-md-4">
                                                            <input type="text" name="morphology" class="form-control input-sm updateElement" id="form_control_1" placeholder="">
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Comment:
                                                        </label>
                                                        <div class="col-md-8">
                                                            <textarea class="form-control updateElement" name="comment" rows="3" placeholder="Enter more text" ></textarea>
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            No. Of Samples:
                                                        </label>
                                                        <div class="col-md-4">
                                                            <input type="text" name="samples_no" class="form-control input-sm updateElement" id="form_control_1" placeholder="" >
                                                            <div class="form-control-focus">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Freezing Media:
                                                        </label>
                                                        <div class="col-md-4">

                                                            <select class="form-control frmedia allupdateselect" id="frmedia" name="media" select-tableName="freezingmedia" data-colName="media">
                                                                <option value="">choose</option>
                                                                {foreach  $freezing_media as $one}
                                                                <option value="{$one->id}">{$one->media}</option>
                                                                {/foreach}

                                                                <option value="-2" class="deleteoptincompo">Delete</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-12">
                                                        <label class="col-md-4 control-label" for="form_control_1">
                                                            Freezing Protocol:
                                                        </label>
                                                        <div class="col-md-4">
                                                            <select class="form-control protocol" id="protocol" name="protocol" data-colName="protocol" select-tableName="freezingprotocol" >
                                                                <option value="">choose</option>
                                                                {foreach  $freezingprotocol as $one}
                                                                <option value="{$one->id}">{$one->protocol}</option>
                                                                {/foreach}

                                                                <option value="-2" class="deleteoptincompo">Delete</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group ">
                                            <div class="col-md-6">
                                                <label class="col-md-4 control-label" for="form_control_1">
                                                    Purpose Of Freezing:
                                                </label>
                                                <div class="col-md-8">

                                                    <div class="col-md-3">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio"  id="IUI" name="purpose" class="md-radiobtn sradio" data-val="0">
                                                                <label for="IUI">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    IUI </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-3">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio"  id="ICSI" name="purpose" class="md-radiobtn sradio" data-val="1">
                                                                <label for="ICSI">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    ICSI </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-3">
                                                        <div class="md-radio-list">
                                                            <div class="md-radio">
                                                                <input type="radio"  id="Preservation" name="purpose" class="md-radiobtn sradio" data-val="1">
                                                                <label for="Preservation">
                                                                    <span></span>
                                                                    <span class="check"></span>
                                                                    <span class="box"></span>
                                                                    Preservation </label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="col-md-12">
                                            <label class="col-md-2 control-label" for="form_control_1">
                                                Location:
                                            </label>
                                            <div class="col-md-5">
                                                <input type="text" name="location" class="form-control input-sm updateElement" id="form_control_1" placeholder="">
                                                <div class="form-control-focus">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="col-md-12">
                                            <label class="col-md-2 control-label" for="form_control_1">
                                                Color Of Pen:
                                            </label>
                                            <div class="col-md-5">
                                                <input type="text" name="color_of_pen" class="form-control input-sm updateElement" id="form_control_1" placeholder="">
                                                <div class="form-control-focus">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group ">
                                            <div class="col-md-12">


                                                <div class="col-md-12">
                                                    <label class="col-md-2 control-label" for="form_control_1">
                                                        Embryology I:
                                                    </label>
                                                    <div class="col-md-5">
                                                        <select class="form-control" id="embryology1" name="embryology1" data-colName="name" select-tableName="awusers"  data-id="{$one.user_id}" >
                                                            <option value="">choose</option>
                                                            {foreach  $users as $one}
                                                            <option value="{$one.user_id}">{$one.name}</option>
                                                            {/foreach}

                                                        </select>
                                                    </div>
                                                </div>
                                                <div class="col-md-12">
                                                    <label class="col-md-2 control-label" for="form_control_1">
                                                        Embryology II:
                                                    </label>
                                                    <div class="col-md-5">
                                                        <select class="form-control" id="embryology2" name="embryology2" data-colName="name" select-tableName="awusers"  data-id="{$one.user_id}" >
                                                            <option value="">choose</option>
                                                            {foreach  $users as $one}
                                                            <option value="{$one.user_id}">{$one.name}</option>
                                                            {/foreach}

                                                        </select>
                                                    </div>

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




                                    <div class="form-actions">
                                        <div class="row">
                                            <div class="col-md-offset-2 col-md-10">
                                                {if $patientId}
                                                <a class="btn default" href="{$hosturl}/controllers/{$controllname}.php?ac=show&patientid={$patientId}">Cancel</a>
                                                {else}
                                                <a class="btn default" href="{$hosturl}/controllers/{$controllname}.php?ac=show">Cancel</a>
                                                {/if}

                                                <button type="submit" class="btn blue">Submit</button>

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

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

            <div class="bootbox modal fade bootbox-alert in" tabindex="-1" role="dialog" aria-hidden="false"  id="edit_model">
                <div class="modal-dialog">
                    <div class="modal-content">
                        <div class="modal-header">
                            <button type="button" class="close" data-dismiss="modal" aria-hidden="true"></button>
                            <h4 class="modal-title"> Edit </h4>
                        </div>
                        <div class="modal-body">
                            <div class="portlet-body form">
                                <form action="" id="" method="post" class="form-horizontal  emptyform" >
                                    <div class="form-body all" >
                                        <!------===========================================------->
                                        <div class="form-group">
                                            <label class="col-md-1 control-label"> </label>
                                            <div class="col-md-10">
                                                <div id="alldatadiv" class="" > </div>
                                            </div>
                                            <label class="col-md-1 control-label"> </label>
                                        </div>

                                        <!------===========================================------->

                                        <!------===========================================------->
                                        <div class="modal-footer">

                                            <button type="button" id="amountcloseinput"   class="btn default" data-dismiss="modal">Close</button>
                                        </div>
                                    </div>
                                </form>
                            </div>
                        </div>
                        <!-- /.modal-content -->
                    </div>
                </div>
            </div>
            <input type="hidden" id="spermfreez" value="1">


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


