ProvidenceXz/Trinity-Health

<%= render 'shared/errors', obj: @case %>

<div class='row'>
  <div class='col-xs-12'>
    <%= form_for([@clinician, @case], :html => {class: "form-horizontal", role: "form", multipart: true}) do |f| %>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :name %>
        </div>
        <div class="col-sm-8">
          <%= f.text_field :name, class: "form-control", placeholder: "Name of patient", autofocus: true %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :age %>
        </div>
        <div class="col-sm-8">
          <%= f.number_field :age, in: 1..100, class: "form-control", placeholder: "Age of patient (Number only)" %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :gender %>
        </div>
        <div class="col-sm-8">
          <%= f.select :gender, [ 'Male', 'Female' ], {}, {class: "form-control"} %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :diagnosis %>
        </div>
        <div class="col-sm-8">
          <%= f.text_area :diagnosis, rows: 10, class: "form-control", placeholder: "Diagnosis of patient" %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :disease_characteristic %>
        </div>
        <div class="col-sm-8">
          <%= f.text_area :disease_characteristic, rows: 10, class: "form-control", placeholder: "Disease characteristics" %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :treatment_history %>
        </div>
        <div class="col-sm-8">
          <%= f.text_area :treatment_history, rows: 10, class: "form-control", placeholder: "Patient's Treatment History" %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :past_medical_history %>
        </div>
        <div class="col-sm-8">
          <%= f.text_area :past_medical_history, rows: 10, class: "form-control", placeholder: "Patient's past medical history" %>
        </div>
      </div>
      <div class="form-group">
        <div class="control-label col-sm-2">
          <%= f.label :attachments %>
        </div>
        <div class="col-sm-8">
          <%= file_field_tag "documents[]", type: :file, multiple: true %>
        </div>
      </div>
      <div class="form-group">
        <div class="col-sm-offset-2 col-sm-10">
          <%= link_to "Cancel", @case_id ? clinician_case_path(@clinician_id, @case_id) : clinician_cases_path(@clinician_id), class: "btn btn-danger btn-lg"%>
          <%= f.submit class: 'btn btn-primary btn-lg' %>
        </div>
      </div>
    <% end %>
  </div>
</div>