

<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>decleration
                        </div>
                    </div>
                    <div class="portlet-body">

                        <!--Begin Semen-->
                        <input type="hidden" id="decleration" value="1"/>
                        <input type="hidden" id="patientId" value="{$patientid}"/>
                        <input type="hidden" id="controllName" value="decleration"/>
                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase">Edit decleration</span>
                                </div>

                            </div>

                            <div class="clearfix"></div>
                            {if $patientId}
                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=updateit&patientid={$patientId}" method="post" >
                                {else}
                                <form action="{$hosturl}/controllers/{$controllname}.php?ac=updateit" method="post" >
                                    {/if}
                                    <input type="hidden" name="editElement_id" value="{$editElement->id}" />
                                    <div class="form-body">

                                        <div class="form-group form-md-line-input">
                                            <label class="col-md-2 control-label" style="text-align: left;" for="form_control_1">title </label>
                                            <div class="col-md-10">
                                                <input type="text" class="form-control" id="form_control_1" placeholder="Enter Title" name="title" required value="{$editElement->title}">
                                                <div class="form-control-focus">
                                                </div>

                                            </div>
                                        </div>


                                        <div class="form-group form-md-line-input">
                                            <label class="col-md-2 control-label" style="text-align: left;" for="form_control_1">Content</label>
                                            <div class="col-md-10">
                                                <textarea class="form-control has-info ckeditor" rows="3" placeholder="Enter more text" name="content" required>{$editElement->content}</textarea>
                                                <div class="form-control-focus">
                                                </div>
                                            </div>
                                        </div>



                                    </div>

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

                                    <!--<ul class="list-group col-md-10" style="float:right;">-->
                                    <!--<li class="list-group-item row ">-->
                                    <div class="form-group col-md-12">
                                        <label class="col-md-2 control-label">Doctor:</label>
                                        <div class="radio-list">
                                            <label class="radio-inline" for="1">
                                                <input type="radio" name="namedoctor" id="1" value="1" {if $editElement->doctor_name == 1}checked{/if} > Yes </label>
                                            <label class="radio-inline" for="2">
                                                <input type="radio" name="namedoctor" id="2" value="0" {if $editElement->doctor_name == 0}checked{/if}> No </label>
                                        </div>
                                    </div>
                                    <div class="form-body" style="display:{if $editElement->doctor_name == 0}none{else}block{/if};"  >
                                        <div class="col-md-6" id="hidedoctor" >
                                            <div class="form-group" >
                                                <label class="col-md-4 control-label" for="form_control_1">Doctor name</label>
                                                <div class="col-md-8">
                                                    <select class="form-control select2me updateElement" data-placeholder="Select..."  name="doctor_id"   data-id="{$one.user_id}">
                                                        <option value="">choose</option>
                                                        {foreach  $py_all_doc as $one}
                                                        <option value="{$one.user_id}"{if $editElement->doctor_id eq $one.user_id}selected{/if}>{$one.name}</option>
                                                        {/foreach}

                                                    </select>
                                                    <div class="form-control-focus">
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <!--</li>-->
                                    <!--<li class="list-group-item row ">-->
                                    <div class="form-group col-md-12">
                                        <label class="col-md-2 control-label">Date:</label>
                                        <div class="radio-list">
                                            <label class="radio-inline" for="3">
                                                <input type="radio" name="namedate" id="3" value="1" {if $editElement->date == 1}checked{/if}> Yes </label>
                                            <label class="radio-inline" for="4">
                                                <input type="radio" name="namedate" id="4" value="0" {if $editElement->date == 0}checked{/if}> No </label>
                                        </div>
                                    </div>
                                    <div class="col-md-12" >

                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="wife_adv" name="wife" class="md-radiobtn updateEmbryoLab"   {if $editElement->wife == 1}checked{/if} value="1" data-colName="radiotype" data-tableName="embryoslab">
                                                    <label for="wife_adv">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Wife Advance</label>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="wife_simple" name="wife" class="md-radiobtn updateEmbryoLab" value="0" data-colName="radiotype" data-tableName="embryoslab"  {if $editElement->wife == 0}checked{/if}>
                                                    <label for="wife_simple">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Wife Simple</label>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="wife_no" name="wife" class="md-radiobtn updateEmbryoLab" {if $editElement->wife == 2}checked{/if} value="2" data-colName="radiotype" data-tableName="embryoslab">
                                                    <label for="wife_no">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        NO   Wife </label>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-12" >
                                        <div class="col-md-6" id="hide_wife_simple">
                                            <div class="form-group" >
                                                <label class="col-md-4 control-label" id="w_n" style="display:{if $editElement->wife == 2}none{else}block{/if};" for="form_control_1">Wife name</label>
                                                <div class="clearfix"></div>

                                                <label class="col-md-4 control-label" style="display:{if $editElement->wife == 0 || $editElement->wife == 2 }none{else}block{/if};" id="w_s" for="form_control_1">Wife Signature</label>
                                                <div class="clearfix"></div>

                                                <label class="col-md-4 control-label" style="display:{if $editElement->wife == 0 || $editElement->wife == 2 }none{else}block{/if};" id="w_ni" for="form_control_1">Wife Nationl Id</label>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-12" >
                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="hus_adv" name="husband" class="md-radiobtn updateEmbryoLab" value="1" data-colName="radiotype"  {if $editElement->husband == 1}checked{/if} data-tableName="embryoslab">
                                                    <label for="hus_adv">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Husband Advance</label>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="hus_simple" name="husband" class="md-radiobtn updateEmbryoLab" value="0" data-colName="radiotype" data-tableName="embryoslab"  {if $editElement->husband == 0}checked{/if}>
                                                    <label for="hus_simple">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Husband Simple</label>
                                                </div>
                                            </div>
                                        </div>    
                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="hus_no" name="husband" class="md-radiobtn "  {if $editElement->husband == 2}checked{/if} value="2" data-colName="radiotype" data-tableName="embryoslab">
                                                    <label for="hus_no">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        No Husband </label>
                                                </div>
                                            </div>
                                        </div>

                                    </div>

                                    <div class="col-md-12" >
                                        <div class="col-md-6" id="hide_husband_simple">
                                            <div class="form-group" >
                                                <label class="col-md-4 control-label"  style="display:{if $editElement->husband == 2}none{else}block{/if};" id="h_n" for="form_control_1">Husband name</label>
                                                <div class="clearfix"></div>

                                                <label class="col-md-4 control-label" style="display:{if $editElement->husband == 0 || $editElement->husband == 2 }none{else}block{/if};" id="h_s" for="form_control_1">Husband Signature</label>
                                                <div class="clearfix"></div>

                                                <label class="col-md-4 control-label" style="display:{if $editElement->husband == 0 || $editElement->husband == 2}none{else}block{/if};" id="h_ni" for="form_control_1">Husband Nationl Id</label>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-12" >
                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="rec_simple" name="reception" class="md-radiobtn updateEmbryoLab" value="1"   {if $editElement->reception == 1}checked{/if}  data-colName="radiotype" data-tableName="embryoslab">
                                                    <label for="rec_simple">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Reception Advance</label>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="col-md-4">
                                            <div class="md-radio-list">
                                                <div class="md-radio">
                                                    <input type="radio" id="rec_adv" name="reception" class="md-radiobtn updateEmbryoLab" value="0" {if $editElement->reception == 0}checked{/if} data-colName="radiotype" data-tableName="embryoslab">
                                                    <label for="rec_adv">
                                                        <span></span>
                                                        <span class="check"></span>
                                                        <span class="box"></span>
                                                        Reception  Simple</label>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <!--                                        </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Husband Name:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="5">
                                                                                            <input type="radio" name="namehusband" id="5" value="1" {if $editElement->husbandname == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="6">
                                                                                            <input type="radio" name="namehusband" id="6" value="0"  {if $editElement->husbandname == 0}checked{/if}> No </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Husband National Id	</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="7">
                                                                                            <input type="radio" name="husband_nationalid" id="7" value="1"  {if $editElement->husbandnationalid == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="8">
                                                                                            <input type="radio" name="husband_nationalid" id="8" value="0"  {if $editElement->husbandnationalid == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Husband Signature simple	:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="9">
                                                                                            <input type="radio" name="husband_signature" id="9" value="1"  {if $editElement->husbandsignature_simple == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="10">
                                                                                            <input type="radio" name="husband_signature" id="10" value="0"  {if $editElement->husbandsignature_simple == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Husband Signature Advance</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="111">
                                                                                            <input type="radio" name="husband_signature_adv" id="111" value="1" {if $editElement->husbandsignature_adv == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="100">
                                                                                            <input type="radio" name="husband_signature_adv" id="100" value="0"  {if $editElement->husbandsignature_adv == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Wife Signature simple:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="121">
                                                                                            <input type="radio" name="wife_signature" id="121" value="1"  {if $editElement->wifesignature_simple == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="133">
                                                                                            <input type="radio" name="wife_signature" id="133" value="0"  {if $editElement->wifesignature_simple == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Wife Signature Advance:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="144">
                                                                                            <input type="radio" name="wife_signature_adv" id="144" value="1"  {if $editElement->wifesignature_adv == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="155">
                                                                                            <input type="radio" name="wife_signature_adv" id="155" value="0"  {if $editElement->wifesignature_adv == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Reception Name simple:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="166">
                                                                                            <input type="radio" name="reception_name" id="166" value="1"  {if $editElement->receptionname_simple == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="177">
                                                                                            <input type="radio" name="reception_name" id="177" value="0"  {if $editElement->receptionname_simple == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Reception Name Advance:</label>
                                                                                    <div class="radio-list" for="40">
                                                                                        <label class="radio-inline">
                                                                                            <input type="radio" name="reception_name_adv" id="40" value="1" {if $editElement->receptionname_adv == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="51">
                                                                                            <input type="radio" name="reception_name_adv" id="51" value="0"  {if $editElement->receptionname_adv == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Wife Name:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="55">
                                                                                            <input type="radio" name="wife_name" id="55" value="1"  {if $editElement->wifename == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="11">
                                                                                            <input type="radio" name="wife_name" id="11" value="0"  {if $editElement->wifename == 0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                                                            <li class="list-group-item row ">
                                                                                <div class="form-group col-md-12">
                                                                                    <label class="col-md-9 control-label">Wife Nationl Id:</label>
                                                                                    <div class="radio-list">
                                                                                        <label class="radio-inline" for="12">
                                                                                            <input type="radio" name="wife_nationalid" id="12" value="1"  {if $editElement->wifenationalid == 1}checked{/if}> Yes </label>
                                                                                        <label class="radio-inline" for="13">
                                                                                            <input type="radio" name="wife_nationalid" id="13" value="0"  {if $editElement->wifenationalid ==0}checked{/if}> No  </label>
                                                                                    </div>
                                                                                </div>
                                    
                                                                            </li>
                                    
                                                                        </ul>-->



                                    <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>
    </div>
</div>


