@php $isEdit = isset($patient); @endphp

<h2 class="h6 text-muted">{{ __('patients::messages.patients.demographics') }}</h2>

{{-- One box, matching the register screen. The parts are still what is stored;
     the request splits the whole name on the way back in. --}}
<div class="row">
    <div class="col-12 col-md-8">
        <x-form.input name="full_name" :label="__('patients::messages.fields.full_name')"
                      :placeholder="__('patients::messages.placeholders.full_name')"
                      :help="__('patients::messages.register.full_name_hint')"
                      :value="$isEdit
                          ? \App\Modules\Patients\Support\PatientName::join($patient->first_name, $patient->middle_name, $patient->last_name)
                          : null"
                      required autofocus />
    </div>
</div>

<div class="row">
    <div class="col-12 col-md-3">
        <x-form.input name="date_of_birth" type="date" :label="__('patients::messages.fields.date_of_birth')"
                      :value="$isEdit ? $patient->date_of_birth?->toDateString() : null" />

        {{--
            An estimated date of birth is flagged rather than hidden. Plenty of
            patients genuinely do not know theirs, and recording a guess as fact
            makes an age-based dose look more certain than it is.
        --}}
        <div class="form-check mb-3">
            <input class="form-check-input" type="checkbox" name="date_of_birth_estimated"
                   id="date_of_birth_estimated" value="1"
                   @checked(old('date_of_birth_estimated', $isEdit ? $patient->date_of_birth_estimated : false))>
            <label class="form-check-label small" for="date_of_birth_estimated">
                {{ __('patients::messages.fields.date_of_birth_estimated') }}
            </label>
        </div>
    </div>

    <div class="col-6 col-md-3">
        <x-form.select name="gender" :label="__('patients::messages.fields.gender')"
                       :options="$genders" :selected="$isEdit ? $patient->gender->value : null" required />
    </div>

    <div class="col-6 col-md-3">
        <x-form.select name="blood_group" :label="__('patients::messages.fields.blood_group')"
                       :options="$bloodGroups" :selected="$isEdit ? $patient->blood_group : null"
                       placeholder="—" />
    </div>

    <div class="col-6 col-md-3">
        <x-form.input name="marital_status" :label="__('patients::messages.fields.marital_status')"
                      :value="$isEdit ? $patient->marital_status : null" />
    </div>
</div>

<hr>

<h2 class="h6 text-muted">{{ __('patients::messages.patients.contact_details') }}</h2>

<div class="row">
    <div class="col-12 col-md-4">
        <x-form.input name="phone" :label="__('patients::messages.fields.phone')"
                      :value="$isEdit ? $patient->phone : null" inputmode="tel" />
    </div>
    <div class="col-12 col-md-4">
        <x-form.input name="alternate_phone" :label="__('patients::messages.fields.alternate_phone')"
                      :value="$isEdit ? $patient->alternate_phone : null" inputmode="tel" />
    </div>
    <div class="col-12 col-md-4">
        <x-form.input name="email" type="email" :label="__('patients::messages.fields.email')"
                      :value="$isEdit ? $patient->email : null" />
    </div>
</div>

<hr>

<h2 class="h6 text-muted">{{ __('patients::messages.patients.identification') }}</h2>

<div class="row">
    <div class="col-12 col-md-4">
        <x-form.input name="national_id" :label="__('patients::messages.fields.national_id')"
                      :value="$isEdit ? $patient->national_id : null" autocomplete="off" />
    </div>
    <div class="col-6 col-md-2">
        <x-form.input name="nationality" :label="__('patients::messages.fields.nationality')"
                      :value="$isEdit ? $patient->nationality : null" maxlength="2" />
    </div>
    <div class="col-12 col-md-6">
        <x-form.input name="occupation" :label="__('patients::messages.fields.occupation')"
                      :value="$isEdit ? $patient->occupation : null" />
    </div>
</div>

<hr>

<h2 class="h6 text-muted">{{ __('patients::messages.patients.address') }}</h2>

<div class="row">
    <div class="col-12 col-md-6">
        <x-form.input name="address_line_1" :label="__('patients::messages.fields.address_line_1')"
                      :value="$isEdit ? $patient->address_line_1 : null" />
    </div>
    <div class="col-12 col-md-6">
        <x-form.input name="address_line_2" :label="__('patients::messages.fields.address_line_2')"
                      :value="$isEdit ? $patient->address_line_2 : null" />
    </div>
    <div class="col-12 col-md-4">
        <x-form.input name="city" :label="__('patients::messages.fields.city')"
                      :value="$isEdit ? $patient->city : null" />
    </div>
    <div class="col-12 col-md-4">
        <x-form.input name="state" :label="__('patients::messages.fields.state')"
                      :value="$isEdit ? $patient->state : null" />
    </div>
    <div class="col-12 col-md-4">
        <x-form.input name="postal_code" :label="__('patients::messages.fields.postal_code')"
                      :value="$isEdit ? $patient->postal_code : null" />
    </div>
</div>

<x-form.textarea name="notes" :label="__('patients::messages.fields.notes')"
                 :value="$isEdit ? $patient->notes : null" rows="2" />