<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>Report
                        </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">Edit </span>
                                </div>

                            </div>

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

                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=reportUpdate" class="clinick awval" method="post">

                                <input type="hidden" id="patientId" name="patientId" value="{$patientId}"/>
                                <input type="hidden" name="id" value="{$oscopic_report->id}"/>

                                <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="{$oscopic_report->created_at}" name="created_at" readonly/>
                                            </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}" {if $data->id|in_array:$oscopic_report->diagnosis}selected="selected"{/if}>{$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="{$oscopic_report->diagnosis_text}" name="diagnosis_text"/>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-2">
                                        <div class="form-group">
                                            <div class="col-md-12" style="margin-top: 25px;">
                                                <label><input type="checkbox" class="form-control" value="1" name="husband" {if $oscopic_report->husband eq 1}checked{/if}/>Husband</label>
                                            </div>
                                        </div>
                                    </div>


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

                                    <div class="form-group ">
                                        <label class="col-md-3 txtl">Operation</label>
                                        <div class="col-md-9">
                                            <!--<select class="form-control oscopic-select" required="required" name="operation_id" id="operation_id" data-placeholder="Select..."
                                                    data-select-tableName="oscopic_operations" data-colName="name">
                                                <option></option>
                                                {foreach $oscopic_operations as $single}
                                                <option value="{$single->id}" {if $single->id eq $oscopic_report->operation_id}selected="selected"{/if}>{$single->name}</option>
                                                {/foreach}
                                                <option value="delete-options-select" class="delete-options-select">Delete</option>
                                            </select>-->
                                            <input type="text" class="form-control" value="{$oscopic_report->operation_text}" name="operation_text"/>
                                        </div>
                                    </div>

                                    <div class="form-group ">
                                        <label class="col-md-3 txtl">Required Examination</label>
                                        <div class="col-md-9">
                                            <!--<select class="form-control oscopic-select" required="required" name="required_examination_id" id="required_examination_id" data-placeholder="Select..."
                                                    data-select-tableName="oscopic_required_examinations" data-colName="name">
                                                <option></option>
                                                {foreach $oscopic_required_examinations as $single}
                                                <option value="{$single->id}" {if $single->id eq $oscopic_report->required_examination_id}selected="selected"{/if}>{$single->name}</option>
                                                {/foreach}
                                                <option value="delete-options-select" class="delete-options-select">Delete</option>
                                            </select>-->
                                            <input type="text" class="form-control" value="{$oscopic_report->required_examination_text}" name="required_examination_text"/>
                                        </div>
                                    </div>

                                    <div class="form-group ">
                                        <label class="col-md-3 txtl">Specimen</label>
                                        <div class="col-md-9">
                                            <!--<select class="form-control oscopic-select" required="required" name="specimen_id" id="specimen_id" data-placeholder="Select..."
                                                    data-select-tableName="oscopic_specimens" data-colName="name">
                                                <option></option>
                                                {foreach $oscopic_specimens as $single}
                                                <option value="{$single->id}" {if $single->id eq $oscopic_report->specimen_id}selected="selected"{/if}>{$single->name}</option>
                                                {/foreach}
                                                <option value="delete-options-select" class="delete-options-select">Delete</option>
                                            </select>-->
                                            <input type="text" class="form-control" value="{$oscopic_report->specimen_text}" name="specimen_text"/>
                                        </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>


<style>
    .delete-options-select {
        background: #a10;
        color: #fff;
        font-weight: 700;
        text-align: center;
        font-size: 14px;
    }
</style>

<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="" method="post" class="form-horizontal emptyform">
                        <div class="form-body">
                            <!------===========================================------->
                            <div>
                                <div id="async_data_container" class=""></div>
                            </div>

                            <div class="modal-footer">
                                <button type="button" id="close-edit-model" class="btn default" data-dismiss="modal">Close</button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
            <!-- /.modal-content -->
        </div>
    </div>
</div>
