@php($patient = $patient ?? null)
@php($profile = $patient?->patientProfile)

<div class="row g-9 mb-7">
    <div class="col-md-4">
        <label class="required form-label">{{ trans('clinic.common.name') }}</label>
        <input type="text" name="name" class="form-control @error('name') is-invalid @enderror"
               value="{{ old('name', $patient->name ?? '') }}">
        @error('name')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
    <div class="col-md-4">
        <label class="form-label">{{ trans('clinic.patients.email') }}</label>
        <input type="email" name="email" class="form-control @error('email') is-invalid @enderror"
               value="{{ old('email', $patient->email ?? '') }}">
        @error('email')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
    <div class="col-md-4">
        <label class="{{ $patient ? '' : 'required' }} form-label">{{ trans('clinic.patients.password') }}</label>
        <input type="password" name="password" class="form-control @error('password') is-invalid @enderror">
        @if($patient)<div class="form-text">{{ trans('clinic.patients.password_hint') }}</div>@endif
        @error('password')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
</div>

<div class="row g-9 mb-7">
    <div class="col-md-4">
        <label class="required form-label">{{ trans('clinic.patients.phone') }}</label>
        <input type="text" name="phone" class="form-control @error('phone') is-invalid @enderror"
               value="{{ old('phone', $patient->phone ?? '') }}">
        @error('phone')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
    <div class="col-md-8">
        <label class="form-label">{{ trans('clinic.patients.address') }}</label>
        <input type="text" name="address" class="form-control @error('address') is-invalid @enderror"
               value="{{ old('address', $patient->address ?? '') }}">
        @error('address')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
</div>

<div class="separator my-6"></div>

<div class="row g-9 mb-7">
    <div class="col-md-4">
        <label class="form-label">{{ trans('clinic.patients.date_of_birth') }}</label>
        <input type="date" name="date_of_birth" class="form-control @error('date_of_birth') is-invalid @enderror"
               max="{{ now()->subDay()->format('Y-m-d') }}"
               value="{{ old('date_of_birth', optional($profile?->date_of_birth)->format('Y-m-d')) }}">
        @error('date_of_birth')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
    <div class="col-md-4">
        <label class="form-label">{{ trans('clinic.patients.gender') }}</label>
        <select name="gender" class="form-select @error('gender') is-invalid @enderror" data-control="select2">
            <option value="">—</option>
            <option value="male" {{ old('gender', $profile->gender ?? '') === 'male' ? 'selected' : '' }}>{{ trans('clinic.patients.gender_male') }}</option>
            <option value="female" {{ old('gender', $profile->gender ?? '') === 'female' ? 'selected' : '' }}>{{ trans('clinic.patients.gender_female') }}</option>
        </select>
        @error('gender')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
    <div class="col-md-4">
        <label class="form-label">{{ trans('clinic.patients.occupation') }}</label>
        <input type="text" name="occupation" class="form-control @error('occupation') is-invalid @enderror"
               value="{{ old('occupation', $profile->occupation ?? '') }}">
        @error('occupation')<div class="invalid-feedback">{{ $message }}</div>@enderror
    </div>
</div>

@can('clinic.medical_records.view')
    <div class="separator my-6"></div>

    @php($medicalHistory = old('medical_history', $profile->medical_history ?? []))
    <h4 class="mb-4">{{ trans('clinic.patient_profile.medical_history') }}</h4>
    <div class="row g-9 mb-7">
        @foreach ($conditionOptions as $conditionOption)
            <div class="col-md-4">
                <div class="form-check">
                    <input type="checkbox" class="form-check-input" id="medical_{{ $conditionOption->code }}" name="medical_history[{{ $conditionOption->code }}]" value="1" @checked(!empty($medicalHistory[$conditionOption->code] ?? false))>
                    <label class="form-check-label" for="medical_{{ $conditionOption->code }}">{{ $conditionOption->name }}</label>
                </div>
            </div>
        @endforeach
        <div class="col-12">
            <label class="form-label">{{ trans('clinic.patient_profile.other') }}</label>
            <input type="text" name="medical_history[other]" value="{{ $medicalHistory['other'] ?? '' }}" class="form-control @error('medical_history.other') is-invalid @enderror">
            @error('medical_history.other')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
    </div>

    @php($surgicalHistory = old('surgical_history', $profile->surgical_history ?? []))
    <h4 class="mb-4">{{ trans('clinic.patient_profile.surgical_history') }}</h4>
    <div class="row g-9 mb-7">
        <div class="col-12">
            <div class="form-check mb-2">
                <input type="checkbox" class="form-check-input" id="had_surgery" name="surgical_history[had_surgery]" value="1" @checked(!empty($surgicalHistory['had_surgery'] ?? false))>
                <label class="form-check-label" for="had_surgery">{{ trans('clinic.patient_profile.had_surgery') }}</label>
            </div>
        </div>
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.surgery_type') }}</label>
            <input type="text" name="surgical_history[type]" value="{{ $surgicalHistory['type'] ?? '' }}" class="form-control @error('surgical_history.type') is-invalid @enderror">
            @error('surgical_history.type')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.surgery_date') }}</label>
            <input type="date" name="surgical_history[date]" value="{{ $surgicalHistory['date'] ?? '' }}" class="form-control @error('surgical_history.date') is-invalid @enderror">
            @error('surgical_history.date')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.hospital') }}</label>
            <input type="text" name="surgical_history[hospital]" value="{{ $surgicalHistory['hospital'] ?? '' }}" class="form-control @error('surgical_history.hospital') is-invalid @enderror">
            @error('surgical_history.hospital')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-12">
            <label class="form-label">{{ trans('clinic.patient_profile.notes') }}</label>
            <textarea name="surgical_history[notes]" rows="2" class="form-control @error('surgical_history.notes') is-invalid @enderror">{{ $surgicalHistory['notes'] ?? '' }}</textarea>
            @error('surgical_history.notes')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
    </div>

    @php($medicationHistory = old('medication_history', $profile->medication_history ?? []))
    <h4 class="mb-4">{{ trans('clinic.patient_profile.medication_history') }}</h4>
    <div class="row g-9 mb-7">
        @foreach ($medicationOptions as $medicationOption)
            <div class="col-md-4">
                <div class="form-check">
                    <input type="checkbox" class="form-check-input" id="medication_{{ $medicationOption->code }}" name="medication_history[{{ $medicationOption->code }}]" value="1" @checked(!empty($medicationHistory[$medicationOption->code] ?? false))>
                    <label class="form-check-label" for="medication_{{ $medicationOption->code }}">{{ $medicationOption->name }}</label>
                </div>
            </div>
        @endforeach
        <div class="col-md-6">
            <label class="form-label">{{ trans('clinic.patient_profile.other') }}</label>
            <input type="text" name="medication_history[other]" value="{{ $medicationHistory['other'] ?? '' }}" class="form-control @error('medication_history.other') is-invalid @enderror">
            @error('medication_history.other')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-12">
            <label class="form-label">{{ trans('clinic.patient_profile.notes') }}</label>
            <textarea name="medication_history[notes]" rows="2" class="form-control @error('medication_history.notes') is-invalid @enderror">{{ $medicationHistory['notes'] ?? '' }}</textarea>
            @error('medication_history.notes')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
    </div>

    <h4 class="mb-4">{{ trans('clinic.patient_profile.allergies') }}</h4>
    <div class="row g-9 mb-7">
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.allergy_type') }}</label>
            <select name="allergy_type" class="form-select @error('allergy_type') is-invalid @enderror" data-control="select2">
                <option value="">—</option>
                <option value="drug" {{ old('allergy_type', $profile->allergy_type ?? '') === 'drug' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.allergy_types.drug') }}</option>
                <option value="food" {{ old('allergy_type', $profile->allergy_type ?? '') === 'food' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.allergy_types.food') }}</option>
                <option value="other" {{ old('allergy_type', $profile->allergy_type ?? '') === 'other' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.allergy_types.other') }}</option>
            </select>
            @error('allergy_type')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.allergy_substance') }}</label>
            <input type="text" name="allergy_substance" value="{{ old('allergy_substance', $profile->allergy_substance ?? '') }}" class="form-control @error('allergy_substance') is-invalid @enderror">
            @error('allergy_substance')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-md-4">
            <label class="form-label">{{ trans('clinic.patient_profile.allergy_severity') }}</label>
            <select name="allergy_severity" class="form-select @error('allergy_severity') is-invalid @enderror" data-control="select2">
                <option value="">—</option>
                <option value="mild" {{ old('allergy_severity', $profile->allergy_severity ?? '') === 'mild' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.severities.mild') }}</option>
                <option value="moderate" {{ old('allergy_severity', $profile->allergy_severity ?? '') === 'moderate' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.severities.moderate') }}</option>
                <option value="severe" {{ old('allergy_severity', $profile->allergy_severity ?? '') === 'severe' ? 'selected' : '' }}>{{ trans('clinic.patient_profile.severities.severe') }}</option>
            </select>
            @error('allergy_severity')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
        <div class="col-12">
            <label class="form-label">{{ trans('clinic.patient_profile.notes') }}</label>
            <textarea name="allergy_notes" rows="2" class="form-control @error('allergy_notes') is-invalid @enderror">{{ old('allergy_notes', $profile->allergy_notes ?? '') }}</textarea>
            @error('allergy_notes')<div class="invalid-feedback">{{ $message }}</div>@enderror
        </div>
    </div>
@endcan