@extends('admin.main')
@section('content')
    <link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css">
    <script src="https://code.jquery.com/jquery-3.6.0.min.js"></script>


    <style>
        body {
            margin: 30px;
            background-color: aliceblue;
        }

        .step {
            display: none;
        }

        .step.active {
            display: block;
        }

        h1 {
            text-align: center;
        }

        .height::after,
        .weight::after {
            margin-left: -75px;
            font-size: 14px;
            font-weight: bold;
            color: #1c3866;
        }

        .width-100 {
            width: 100%;
        }

        #comment {
            background-color: rgb(242, 240, 240);
            padding: 30px;
            border-radius: 10px;
            box-shadow: 0 10px 20px rgba(0, 0, 0, 0.2);
        }

        .error-border {
            border: 2px solid #dc3545 !important;
        }

        .form-row {
            align-items: end;
        }
    </style>



    <div class="container">
        <h2 class="text-center">
            Medical History and Presenting Complaints Form

        </h2>



        @if (Session::has('error_message'))
            <div class="alert alert-secondary dark alert-dismissible fade show" role="alert">
                {{-- <strong>Error ! </strong> --}}
                {{ Session::get('error_message') }}.
                {{-- <button class="btn-close" type="button" data-bs-dismiss="alert" aria-label="Close"
                                    data-bs-original-title="" title=""></button> --}}
            </div>
        @endif

        @if (Session::has('success_message'))
            <div class="alert alert-success dark alert-dismissible fade show" role="alert">
                {{-- <strong>Success ! </strong> --}}
                {{ Session::get('success_message') }}.
                {{-- <button class="btn-close" type="button" data-bs-dismiss="alert" aria-label="Close"
                                    data-bs-original-title="" title=""></button> --}}
            </div>
        @endif

        @if ($errors->any())
            <div class="alert alert-danger">
                <ul>
                    @foreach ($errors->all() as $error)
                        <li>{{ $error }}</li>
                    @endforeach
                </ul>
            </div>
        @endif



        <form id="multiStepForm" method="post"
            @if (!empty($UpdateId) && $UpdateId > 0) action="{{ route('UpdateMedicalHistory') }}/{{ $UpdateId }}" @else   action="{{ route('CreateMedicalHistory') }}" @endif
            enctype="multipart/form-data">
            @csrf


            <div class="step active" id="step1">
                <h3>Patient Information</h3>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="gr_no">GR.No.</label>
                            <input type="text" class="form-control" id="GrNo" name="GrNo" required
                                @if (!empty($GeneralInfo['GrNo'])) value="{{ $GeneralInfo['GrNo'] }}"
                        @else
                        value="{{ old('GrNo') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="name">Name</label>
                            <input type="text" class="form-control" id="name" name="name"
                                @if (!empty($GeneralInfo['name'])) value="{{ $GeneralInfo['name'] }}"
                        @else
                        value="{{ old('name') }}" @endif
                                required>
                        </div>
                    </div>


                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="class">Class</label>
                            <input type="text" class="form-control" id="class" name="class"
                                @if (!empty($GeneralInfo['class'])) value="{{ $GeneralInfo['class'] }}"
                        @else
                        value="{{ old('class') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="dob">Date of Birth</label>
                            <input type="date" class="form-control" id="dob" name="dob"
                                @if (!empty($GeneralInfo['dob'])) value="{{ $GeneralInfo['dob'] }}"
                        @else
                        value="{{ old('dob') }}" @endif
                                required>
                        </div>
                    </div>


                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="gender">Gender </label>
                            <select class="form-control" id="gender" name="gender" required>
                                <option value="">Select</option>
                                <option value="male" @if (!empty($GeneralInfo['gender']) && $GeneralInfo['gender'] == 'male') selected @endif>Male</option>
                                <option value="female" @if (!empty($GeneralInfo['gender']) && $GeneralInfo['gender'] == 'female') selected @endif>Female</option>
                                <option value="other" @if (!empty($GeneralInfo['gender']) && $GeneralInfo['gender'] == 'other') selected @endif>Other</option>
                            </select>

                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="BloodGroup">Blood group</label>
                            <select class="form-control" id="BloodGroup" name="BloodGroup" required>
                                <option value="" @if (empty($GeneralInfo['BloodGroup'])) selected @endif>Select</option>
                                <option value="A+" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'A+') selected @endif>A+</option>
                                <option value="A-" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'A-') selected @endif>A-</option>
                                <option value="B+" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'B+') selected @endif>B+</option>
                                <option value="B-" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'B-') selected @endif>B-</option>
                                <option value="O+" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'O+') selected @endif>O+</option>
                                <option value="O-" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'O-') selected @endif>O-</option>
                                <option value="AB+" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'AB+') selected @endif>AB+</option>
                                <option value="AB-" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'AB-') selected @endif>AB-</option>
                                <option value="Unknown" @if (!empty($GeneralInfo['BloodGroup']) && $GeneralInfo['BloodGroup'] == 'Unknown') selected @endif>Unknown</option>
                            </select>

                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="contact">Contact</label>
                            <input type="tel" class="form-control" id="contact" name="contact"
                                @if (!empty($GeneralInfo['contact'])) value="{{ $GeneralInfo['contact'] }}"
                        @else
                        value="{{ old('contact') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="email">Email</label>
                            <input type="email" class="form-control" id="email" name="email"
                                @if (!empty($GeneralInfo['email'])) value="{{ $GeneralInfo['email'] }}"
                        @else
                        value="{{ old('email') }}" @endif
                                required>
                        </div>
                    </div>
                    <hr>
                    <h6 class="w-100">
                        Emergency Contact
                    </h6>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="emergency_name">Name</label>
                            <input type="text" class="form-control" id="emergency_name" name="emergency_name"
                                @if (!empty($GeneralInfo['emergency_name'])) value="{{ $GeneralInfo['emergency_name'] }}"
                        @else
                        value="{{ old('emergency_name') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="emergency_relationship">Relationship</label>
                            <input type="text" class="form-control" id="emergency_relationship"
                                name="emergency_relationship"
                                @if (!empty($GeneralInfo['emergency_relationship'])) value="{{ $GeneralInfo['emergency_relationship'] }}"
                        @else
                        value="{{ old('emergency_relationship') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="emergency_contact">Contact</label>
                            <input type="tel" class="form-control" id="emergency_contact" name="emergency_contact"
                                @if (!empty($GeneralInfo['emergency_contact'])) value="{{ $GeneralInfo['emergency_contact'] }}"
                        @else
                        value="{{ old('emergency_contact') }}" @endif
                                required>
                        </div>
                    </div>
                </div>
                <button type="button" class="btn btn-primary nextStep">Next</button>
            </div>


            <div class="step  " id="step2">
                <h3>Presenting Complaints</h3>

                <h6 class="w-100">
                    Main Complaint
                </h6>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="description">Description</label>
                            <input type="text" class="form-control" id="Description" name="Description"
                                @if (!empty($MainComplaint['Description'])) value="{{ $MainComplaint['Description'] }}"
                            @else
                            value="{{ old('Description') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="onset">Onset</label>
                            <input type="text" class="form-control" id="Onset" name="Onset"
                                @if (!empty($MainComplaint['Onset'])) value="{{ $MainComplaint['Onset'] }}"
                            @else
                            value="{{ old('Onset') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="duration">Duration</label>
                            <input type="text" class="form-control" id="Duration" name="Duration"
                                @if (!empty($MainComplaint['Duration'])) value="{{ $MainComplaint['Duration'] }}"
                            @else
                            value="{{ old('Duration') }}" @endif
                                required>




                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="severity">Severity (Scale 1-10)</label>
                            <select class="form-control" id="Severity" name="Severity" required>
                                <option value="" @if (empty($MainComplaint['Severity']) && !old('Severity')) selected @endif>Select</option>
                                <option value="1" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '1') || old('Severity') == '1') selected @endif>1</option>
                                <option value="2" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '2') || old('Severity') == '2') selected @endif>2</option>
                                <option value="3" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '3') || old('Severity') == '3') selected @endif>3</option>
                                <option value="4" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '4') || old('Severity') == '4') selected @endif>4</option>
                                <option value="5" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '5') || old('Severity') == '5') selected @endif>5</option>
                                <option value="6" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '6') || old('Severity') == '6') selected @endif>6</option>
                                <option value="7" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '7') || old('Severity') == '7') selected @endif>7</option>
                                <option value="8" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '8') || old('Severity') == '8') selected @endif>8</option>
                                <option value="9" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '9') || old('Severity') == '9') selected @endif>9</option>
                                <option value="10" @if ((!empty($MainComplaint) && $MainComplaint['Severity'] == '10') || old('Severity') == '10') selected @endif>10</option>
                            </select>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="RelievingFactor">Aggravating/Relieving Factors</label>
                            <input type="text" class="form-control" id="RelievingFactor" name="RelievingFactor"
                                @if (!empty($MainComplaint['RelievingFactor'])) value="{{ $MainComplaint['RelievingFactor'] }}"
                            @else
                            value="{{ old('RelievingFactor') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="associated_symptoms">Associated Symptoms</label>
                            <input type="text" class="form-control" id="AssociatedSymptoms" name="AssociatedSymptoms"
                                @if (!empty($MainComplaint['AssociatedSymptoms'])) value="{{ $MainComplaint['AssociatedSymptoms'] }}"
                            @else
                            value="{{ old('AssociatedSymptoms') }}" @endif
                                required>
                        </div>
                    </div>
                </div>

                <h6 class="w-100">
                    Secondary Complaints (if any)
                </h6>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Description2">Description</label>
                            <input type="text" class="form-control" id="Description2" name="Description2"
                                @if (!empty($SecondaryComplain['Description'])) value="{{ $SecondaryComplain['Description'] }}"
                            @else
                            value="{{ old('Description2') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Onset2">Onset</label>
                            <input type="text" class="form-control" id="Onset2" name="Onset2"
                                @if (!empty($SecondaryComplain['Onset'])) value="{{ $SecondaryComplain['Onset'] }}"
                            @else
                            value="{{ old('Onset2') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Duration2">Duration</label>
                            <input type="text" class="form-control" id="Duration2" name="Duration2"
                                @if (!empty($SecondaryComplain['Duration'])) value="{{ $SecondaryComplain['Duration'] }}"
                            @else
                            value="{{ old('Duration2') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Severity2">Severity (Scale 1-10)</label>

                            <select class="form-control" id="Severity2" name="Severity2" required>
                                <option value="" @if (empty($SecondaryComplain['Severity']) && !old('Severity2')) selected @endif>Select</option>

                                @foreach (range(1, 10) as $number)
                                    <option value="{{ $number }}"
                                        @if (($SecondaryComplain['Severity'] ?? old('Severity2')) == $number) selected @endif>{{ $number }}</option>
                                @endforeach
                            </select>


                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="RelievingFactor2">Aggravating/Relieving Factors</label>
                            <input type="text" class="form-control" id="RelievingFactor2" name="RelievingFactor2"
                                @if (!empty($SecondaryComplain['RelievingFactor'])) value="{{ $SecondaryComplain['RelievingFactor'] }}"
                            @else
                            value="{{ old('RelievingFactor2') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="AssociatedSymptoms2">Associated Symptoms</label>
                            <input type="text" class="form-control" id="AssociatedSymptoms2"
                                name="AssociatedSymptoms2"
                                @if (!empty($SecondaryComplain['AssociatedSymptoms'])) value="{{ $SecondaryComplain['AssociatedSymptoms'] }}"
                                @else
                                value="{{ old('AssociatedSymptoms2') }}" @endif
                                required>
                        </div>
                    </div>
                </div>

                <h6 class="w-100">
                    Recent Changes or Symptoms of Concern
                </h6>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Description3">Description</label>
                            <input type="text" class="form-control" id="Description3" name="Description3"
                                @if (!empty($RecentChangesOrConcern['Description'])) value="{{ $RecentChangesOrConcern['Description'] }}"
                            @else
                            value="{{ old('Description3') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Onset3">Onset</label>
                            <input type="text" class="form-control" id="Onset3" name="Onset3"
                                @if (!empty($RecentChangesOrConcern['Onset'])) value="{{ $RecentChangesOrConcern['Onset'] }}"
                            @else
                            value="{{ old('Onset3') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Duration3">Duration</label>
                            <input type="text" class="form-control" id="Duration3" name="Duration3"
                                @if (!empty($RecentChangesOrConcern['Duration'])) value="{{ $RecentChangesOrConcern['Duration'] }}"
                            @else
                            value="{{ old('Duration3') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Severity3">Severity (Scale 1-10)</label>



                            <select class="form-control" id="Severity3" name="Severity3" required>
                                <option value="" @if (empty($RecentChangesOrConcern['Severity']) && !old('Severity3')) selected @endif>Select</option>
                                <option value="1"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '1') selected @elseif(old('Severity3') == '1') selected @endif>
                                    1</option>
                                <option value="2"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '2') selected @elseif(old('Severity3') == '2') selected @endif>
                                    2</option>
                                <option value="3"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '3') selected @elseif(old('Severity3') == '3') selected @endif>
                                    3</option>
                                <option value="4"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '4') selected @elseif(old('Severity3') == '4') selected @endif>
                                    4</option>
                                <option value="5"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '5') selected @elseif(old('Severity3') == '5') selected @endif>
                                    5</option>
                                <option value="6"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '6') selected @elseif(old('Severity3') == '6') selected @endif>
                                    6</option>
                                <option value="7"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '7') selected @elseif(old('Severity3') == '7') selected @endif>
                                    7</option>
                                <option value="8"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '8') selected @elseif(old('Severity3') == '8') selected @endif>
                                    8</option>
                                <option value="9"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '9') selected @elseif(old('Severity3') == '9') selected @endif>
                                    9</option>
                                <option value="10"
                                    @if (!empty($RecentChangesOrConcern['Severity']) && $RecentChangesOrConcern['Severity'] == '10') selected @elseif(old('Severity3') == '10') selected @endif>
                                    10</option>
                            </select>


                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="RelievingFactor3">Aggravating/Relieving Factors</label>
                            <input type="text" class="form-control" id="RelievingFactor3" name="RelievingFactor3"
                                @if (!empty($RecentChangesOrConcern['RelievingFactor'])) value="{{ $RecentChangesOrConcern['RelievingFactor'] }}"
                            @else
                            value="{{ old('RelievingFactor3') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="AssociatedSymptoms3">Associated Symptoms</label>
                            <input type="text" class="form-control" id="AssociatedSymptoms3"
                                name="AssociatedSymptoms3"
                                @if (!empty($RecentChangesOrConcern['AssociatedSymptoms'])) value="{{ $RecentChangesOrConcern['AssociatedSymptoms'] }}"
                                @else
                                value="{{ old('AssociatedSymptoms3') }}" @endif
                                required>
                        </div>
                    </div>

                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>


            <div class="step " id="step3">
                <h3>VITAL SIGNS</h3>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="pulse">Pulse</label>
                            <input type="text" class="form-control" id="pulse" name="pulse"
                                @if (!empty($VitalSign['pulse'])) value="{{ $VitalSign['pulse'] }}"
                            @else
                            value="{{ old('pulse') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="temperature">Temperature</label>
                            <input type="text" class="form-control" id="temperature" name="temperature"
                                @if (!empty($VitalSign['temperature'])) value="{{ $VitalSign['temperature'] }}"
                            @else
                            value="{{ old('temperature') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="bp">bp</label>
                            <input type="text" class="form-control" id="bp" name="bp"
                                @if (!empty($VitalSign['bp'])) value="{{ $VitalSign['bp'] }}"
                            @else
                            value="{{ old('bp') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="RespiratoryRate">Respiratory Rate</label>
                            <input type="text" class="form-control" id="RespiratoryRate" name="RespiratoryRate"
                                @if (!empty($VitalSign['RespiratoryRate'])) value="{{ $VitalSign['RespiratoryRate'] }}"
                            @else
                            value="{{ old('RespiratoryRate') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="bmi_weight">BMI Weight</label>
                            <input type="text" class="form-control" id="bmi_weight" name="bmi_weight"
                                @if (!empty($VitalSign['bmi_weight'])) value="{{ $VitalSign['bmi_weight'] }}"
                            @else
                            value="{{ old('bmi_weight') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="bmi_height">BMI Height</label>
                            <input type="text" class="form-control" id="bmi_height" name="bmi_height"
                                @if (!empty($VitalSign['bmi_height'])) value="{{ $VitalSign['bmi_height'] }}"
                            @else
                            value="{{ old('bmi_height') }}" @endif
                                required>
                        </div>
                    </div>
                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>

            <div class="step " id="step4">
                <h3>Fever History</h3>
                <h6 class="w-100">
                    Temperature Measurement
                </h6>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="actual_temperature">Actual temperature measured (e.g., with a thermometer)</label>
                            <input type="text" class="form-control" id="actual_temperature" name="actual_temperature"
                                @if (!empty($FeverHistory['temperature'])) value="{{ $FeverHistory['temperature'] }}"
                            @else
                            value="{{ old('actual_temperature') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="description_fever">Description of fever</label>



                            <select class="form-control" id="description_fever" name="description_fever" required>
                                <option value="" @if (empty($FeverHistory['Description_of_fever']) && !old('description_fever')) selected @endif>Select</option>

                                <option value="Low-grade" @if (
                                    (!empty($FeverHistory) && $FeverHistory['Description_of_fever'] == 'Low-grade') ||
                                        old('description_fever') == 'Low-grade') selected @endif>Low-grade
                                </option>
                                <option value="High-grade" @if (
                                    (!empty($FeverHistory) && $FeverHistory['Description_of_fever'] == 'High-grade') ||
                                        old('description_fever') == 'High-grade') selected @endif>High-grade
                                </option>
                                <option value="Intermittent" @if (
                                    (!empty($FeverHistory) && $FeverHistory['Description_of_fever'] == 'Intermittent') ||
                                        old('description_fever') == 'Intermittent') selected @endif>
                                    Intermittent</option>
                                <option value="none" @if ((!empty($FeverHistory) && $FeverHistory['Description_of_fever'] == 'none') || old('description_fever') == 'none') selected @endif>None</option>
                            </select>

                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="onset_duration">Onset and Duration</label>



                            <select class="form-control" id="onset_duration" name="onset_duration" required>
                                <option value="" @if (empty($FeverHistory['Onset_Duration']) && !old('onset_duration')) selected @endif>Select</option>
                                <option value="Sudden onset" @if (
                                    (!empty($FeverHistory) && $FeverHistory['Onset_Duration'] == 'Sudden onset') ||
                                        old('onset_duration') == 'Sudden onset') selected @endif>Sudden
                                    onset</option>
                                <option value="Gradual onset" @if (
                                    (!empty($FeverHistory) && $FeverHistory['Onset_Duration'] == 'Gradual onset') ||
                                        old('onset_duration') == 'Gradual onset') selected @endif>Gradual
                                    onset</option>
                                <option value="Duration of fever episodes"
                                    @if (
                                        (!empty($FeverHistory) && $FeverHistory['Onset_Duration'] == 'Duration of fever episodes') ||
                                            old('onset_duration') == 'Duration of fever episodes') selected @endif>Duration of fever episodes</option>
                                <option value="none" @if ((!empty($FeverHistory) && $FeverHistory['Onset_Duration'] == 'none') || old('onset_duration') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6" id="durationInput"
                        @if (!empty($FeverHistory['Duration'])) @else
                    
                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="duration_fever_episodes">Duration of fever episodes</label>
                            <input type="text" class="form-control" name="duration_fever_episodes"
                                @if (!empty($FeverHistory['Duration'])) value="{{ $FeverHistory['Duration'] }}"
                            @else
                            value="{{ old('duration_fever_episodes') }}" @endif>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="pattern_fever">Pattern of Fever</label>


                            <select class="form-control" id="pattern_fever" name="pattern_fever" required>
                                <option value="" @if (empty($FeverHistory['PatternOfFever']) && !old('pattern_fever')) selected @endif>Select</option>
                                <option value="Intermittent" @if (
                                    (!empty($FeverHistory) && $FeverHistory['PatternOfFever'] == 'Intermittent') ||
                                        old('pattern_fever') == 'Intermittent') selected @endif>
                                    Intermittent (fever spikes followed by normal temperature)</option>
                                <option value="Remittent" @if ((!empty($FeverHistory) && $FeverHistory['PatternOfFever'] == 'Remittent') || old('pattern_fever') == 'Remittent') selected @endif>Remittent
                                    (fever fluctuates but does not return to normal)</option>
                                <option value="Continuous" @if ((!empty($FeverHistory) && $FeverHistory['PatternOfFever'] == 'Continuous') || old('pattern_fever') == 'Continuous') selected @endif>Continuous
                                    (fever persists without significant fluctuation)</option>
                                <option value="Fever associated with chills or rigors"
                                    @if (
                                        (!empty($FeverHistory) && $FeverHistory['PatternOfFever'] == 'Fever associated with chills or rigors') ||
                                            old('pattern_fever') == 'Fever associated with chills or rigors') selected @endif>Fever associated with chills or
                                    rigors</option>
                                <option value="none" @if ((!empty($FeverHistory) && $FeverHistory['PatternOfFever'] == 'none') || old('pattern_fever') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="associated_symptoms">Associated Symptoms</label>

                            <select class="form-control" id="associated_symptoms1" name="associated_symptoms1" required>
                                <option value="" @if (empty($FeverHistory['AssociatedSymptoms']) && !old('associated_symptoms1')) selected @endif>Select</option>
                                <option value="Headache" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Headache') ||
                                        old('associated_symptoms1') == 'Headache') selected @endif>Headache
                                </option>
                                <option value="Body aches" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Body aches') ||
                                        old('associated_symptoms1') == 'Body aches') selected @endif>Body aches
                                </option>
                                <option value="Fatigue" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Fatigue') ||
                                        old('associated_symptoms1') == 'Fatigue') selected @endif>Fatigue
                                </option>
                                <option value="Sweating" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Sweating') ||
                                        old('associated_symptoms1') == 'Sweating') selected @endif>Sweating
                                </option>
                                <option value="Cough" @if ((!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Cough') || old('associated_symptoms1') == 'Cough') selected @endif>Cough</option>
                                <option value="Sore throat" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Sore throat') ||
                                        old('associated_symptoms1') == 'Sore throat') selected @endif>Sore
                                    throat</option>
                                <option value="Runny nose" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Runny nose') ||
                                        old('associated_symptoms1') == 'Runny nose') selected @endif>Runny nose
                                </option>
                                <option value="Shortness of breath" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Shortness of breath') ||
                                        old('associated_symptoms1') == 'Shortness of breath') selected @endif>
                                    Shortness of breath</option>
                                <option value="Nausea" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Nausea') ||
                                        old('associated_symptoms1') == 'Nausea') selected @endif>Nausea</option>
                                <option value="Vomiting" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Vomiting') ||
                                        old('associated_symptoms1') == 'Vomiting') selected @endif>Vomiting
                                </option>
                                <option value="Diarrhea" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Diarrhea') ||
                                        old('associated_symptoms1') == 'Diarrhea') selected @endif>Diarrhea
                                </option>
                                <option value="Abdominal pain" @if (
                                    (!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Abdominal pain') ||
                                        old('associated_symptoms1') == 'Abdominal pain') selected @endif>
                                    Abdominal pain</option>
                                <option value="Rash" @if ((!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'Rash') || old('associated_symptoms1') == 'Rash') selected @endif>Rash</option>
                                <option value="none" @if ((!empty($FeverHistory) && $FeverHistory['AssociatedSymptoms'] == 'none') || old('associated_symptoms1') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="recent_exposures">Recent Exposures or Travel</label>
                            <select class="form-control" id="recent_exposures" name="recent_exposures" required>
                                <option value="" @if (empty($FeverHistory['RecentExposuresOrTravel']) && !old('recent_exposures')) selected @endif>Select
                                </option>
                                <option value="Exposure to individuals with infectious illnesses"
                                    @if (
                                        (!empty($FeverHistory) &&
                                            $FeverHistory['RecentExposuresOrTravel'] == 'Exposure to individuals with infectious illnesses') ||
                                            old('recent_exposures') == 'Exposure to individuals with infectious illnesses') selected @endif>Exposure to individuals with
                                    infectious illnesses</option>
                                <option value="Travel to regions with endemic infectious diseases"
                                    @if (
                                        (!empty($FeverHistory) &&
                                            $FeverHistory['RecentExposuresOrTravel'] == 'Travel to regions with endemic infectious diseases') ||
                                            old('recent_exposures') == 'Travel to regions with endemic infectious diseases') selected @endif>Travel to regions with endemic
                                    infectious diseases</option>
                                <option value="none" @if ((!empty($FeverHistory) && $FeverHistory['RecentExposuresOrTravel'] == 'none') || old('recent_exposures') == 'none') selected @endif>none</option>
                            </select>

                        </div>
                    </div>
                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
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            </div>

            <div class="step " id="step5">
                <h3>Headache</h3>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="ClusterHeadache">Cluster Headache</label>



                            <select class="form-control" id="ClusterHeadache" name="ClusterHeadache" required>
                                <option value="" @if (empty($Headache['ClusterHeadache']) && !old('ClusterHeadache')) selected @endif>Select
                                </option>
                                <option value="One-sided pain" @if (
                                    (!empty($Headache) && $Headache['ClusterHeadache'] == 'One-sided pain') ||
                                        old('ClusterHeadache') == 'One-sided pain') selected @endif>
                                    One-sided pain, typically behind or around one eye</option>
                                <option value="Rapid onset of severe pain"
                                    @if (
                                        (!empty($Headache) && $Headache['ClusterHeadache'] == 'Rapid onset of severe pain') ||
                                            old('ClusterHeadache') == 'Rapid onset of severe pain') selected @endif>Rapid onset of severe pain
                                </option>
                                <option value="Shorter duration (15 minutes to 3 hours)"
                                    @if (
                                        (!empty($Headache) && $Headache['ClusterHeadache'] == 'Shorter duration (15 minutes to 3 hours)') ||
                                            old('ClusterHeadache') == 'Shorter duration (15 minutes to 3 hours)') selected @endif>Shorter duration (15 minutes to 3
                                    hours)</option>
                                <option value="Associated symptoms: tearing of the eye, nasal congestion, restlessness"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['ClusterHeadache'] == 'Associated symptoms: tearing of the eye, nasal congestion, restlessness') ||
                                            old('ClusterHeadache') == 'Associated symptoms: tearing of the eye, nasal congestion, restlessness') selected @endif>Associated symptoms: tearing of
                                    the eye, nasal congestion, restlessness</option>
                                <option
                                    value="Occurs in clusters over weeks to months (episodic) or persistently (chronic)"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['ClusterHeadache'] ==
                                                'Occurs in clusters over weeks to months (episodic) or persistently (chronic)') ||
                                            old('ClusterHeadache') == 'Occurs in clusters over weeks to months (episodic) or persistently (chronic)') selected @endif>Occurs in clusters over weeks to
                                    months (episodic) or persistently (chronic)</option>
                                <option value="none" @if ((!empty($Headache) && $Headache['ClusterHeadache'] == 'none') || old('ClusterHeadache') == 'none') selected @endif>none</option>
                            </select>


                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Migraine">Migraine</label>

                            <select class="form-control" id="Migraine" name="Migraine" required>
                                <option value="" @if (empty($Headache['Migraine']) && !old('Migraine')) selected @endif>Select
                                </option>
                                <option
                                    value="One-sided or bilateral pain, often localized to the temple, forehead, or around the eyes"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['Migraine'] ==
                                                'One-sided or bilateral pain, often localized to the temple, forehead, or around the eyes') ||
                                            old('Migraine') == 'One-sided or bilateral pain, often localized to the temple, forehead, or around the eyes') selected @endif>One-sided or bilateral pain, often
                                    localized to the temple, forehead, or around the eyes</option>
                                <option value="Longer duration compared to cluster headaches (4 to 72 hours if untreated)"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['Migraine'] == 'Longer duration compared to cluster headaches (4 to 72 hours if untreated)') ||
                                            old('Migraine') == 'Longer duration compared to cluster headaches (4 to 72 hours if untreated)') selected @endif>Longer duration compared to
                                    cluster headaches (4 to 72 hours if untreated)</option>
                                <option value="Associated with nausea, vomiting, photophobia, and phonophobia"
                                    @if (
                                        (!empty($Headache) && $Headache['Migraine'] == 'Associated with nausea, vomiting, photophobia, and phonophobia') ||
                                            old('Migraine') == 'Associated with nausea, vomiting, photophobia, and phonophobia') selected @endif>Associated with nausea, vomiting,
                                    photophobia, and phonophobia</option>
                                <option
                                    value="May have prodromal symptoms (aura) such as visual disturbances or sensory changes"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['Migraine'] == 'May have prodromal symptoms (aura) such as visual disturbances or sensory changes') ||
                                            old('Migraine') == 'May have prodromal symptoms (aura) such as visual disturbances or sensory changes') selected @endif>May have prodromal symptoms (aura)
                                    such as visual disturbances or sensory changes</option>
                                <option
                                    value="Triggers may include hormonal changes, certain foods, stress, or environmental factors"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['Migraine'] ==
                                                'Triggers may include hormonal changes, certain foods, stress, or environmental factors') ||
                                            old('Migraine') == 'Triggers may include hormonal changes, certain foods, stress, or environmental factors') selected @endif>Triggers may include hormonal
                                    changes, certain foods, stress, or environmental factors</option>
                                <option value="none" @if ((!empty($Headache) && $Headache['Migraine'] == 'none') || old('Migraine') == 'none') selected @endif>none</option>
                            </select>


                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="TensionHeadache">Tension Headache</label>



                            <select class="form-control" id="TensionHeadache" name="TensionHeadache" required>
                                <option value="" @if (empty($Headache['TensionHeadache']) && !old('TensionHeadache')) selected @endif>Select
                                </option>
                                <option
                                    value="Bilateral pain, often described as a band-like pressure or tightness around the head"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['TensionHeadache'] ==
                                                'Bilateral pain, often described as a band-like pressure or tightness around the head') ||
                                            old('TensionHeadache') ==
                                                'Bilateral pain, often described as a band-like pressure or tightness around the head') selected @endif>Bilateral pain, often described as
                                    a band-like pressure or tightness around the head</option>
                                <option value="Gradual onset of mild to moderate pain"
                                    @if (
                                        (!empty($Headache) && $Headache['TensionHeadache'] == 'Gradual onset of mild to moderate pain') ||
                                            old('TensionHeadache') == 'Gradual onset of mild to moderate pain') selected @endif>Gradual onset of mild to moderate
                                    pain</option>
                                <option value="Often triggered by stress, poor posture, or muscle tension"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['TensionHeadache'] == 'Often triggered by stress, poor posture, or muscle tension') ||
                                            old('TensionHeadache') == 'Often triggered by stress, poor posture, or muscle tension') selected @endif>Often triggered by stress, poor
                                    posture, or muscle tension</option>
                                <option
                                    value="Usually no associated symptoms of nausea, vomiting, or sensitivity to light/sound"
                                    @if (
                                        (!empty($Headache) &&
                                            $Headache['TensionHeadache'] ==
                                                'Usually no associated symptoms of nausea, vomiting, or sensitivity to light/sound') ||
                                            old('TensionHeadache') == 'Usually no associated symptoms of nausea, vomiting, or sensitivity to light/sound') selected @endif>Usually no associated symptoms of
                                    nausea, vomiting, or sensitivity to light/sound</option>
                                <option value="Can be chronic (frequent episodes) or episodic"
                                    @if (
                                        (!empty($Headache) && $Headache['TensionHeadache'] == 'Can be chronic (frequent episodes) or episodic') ||
                                            old('TensionHeadache') == 'Can be chronic (frequent episodes) or episodic') selected @endif>Can be chronic (frequent episodes)
                                    or episodic</option>
                                <option value="none" @if ((!empty($Headache) && $Headache['TensionHeadache'] == 'none') || old('TensionHeadache') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>


                </div>

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            </div>

            <div class="step  " id="step6">
                <h3>MENINGITIS</h3>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="onset_progression">Onset and Progression</label>


                            <select class="form-control" id="onset_progression" name="onset_progression" required>
                                <option value="" @if (empty($Meningitis['OnsetAndProgression']) && !old('onset_progression')) selected @endif>Select
                                </option>
                                <option value="Sudden onset of symptoms"
                                    @if (
                                        (!empty($Meningitis) && $Meningitis['OnsetAndProgression'] == 'Sudden onset of symptoms') ||
                                            old('onset_progression') == 'Sudden onset of symptoms') selected @endif>Sudden onset of symptoms</option>
                                <option value="Rapid progression of symptoms over hours to days"
                                    @if (
                                        (!empty($Meningitis) && $Meningitis['OnsetAndProgression'] == 'Rapid progression of symptoms over hours to days') ||
                                            old('onset_progression') == 'Rapid progression of symptoms over hours to days') selected @endif>Rapid progression of symptoms over
                                    hours to days</option>
                                <option value="none" @if ((!empty($Meningitis) && $Meningitis['OnsetAndProgression'] == 'none') || old('onset_progression') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Headache">Headache</label>


                            <select class="form-control" id="Headache" name="Headache" required>
                                <option value="" @if (empty($Meningitis['Headache']) && !old('Headache')) selected @endif>Select
                                </option>
                                <option value="Headache is typically severe"
                                    @if (
                                        (!empty($Meningitis) && $Meningitis['Headache'] == 'Headache is typically severe') ||
                                            old('Headache') == 'Headache is typically severe') selected @endif>Headache is typically severe
                                </option>
                                <option value="Headache may be described as the worst headache of my life"
                                    @if (
                                        (!empty($Meningitis) && $Meningitis['Headache'] == 'Headache may be described as the worst headache of my life') ||
                                            old('Headache') == 'Headache may be described as the worst headache of my life') selected @endif>Headache may be described as "the
                                    worst headache of my life"</option>
                                <option value="none" @if ((!empty($Meningitis) && $Meningitis['Headache'] == 'none') || old('Headache') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Fever">Fever</label>
                            <select class="form-control" id="Fever" name="Fever" required>
                                <option value="" @if (empty($Meningitis['Fever']) && !old('Fever')) selected @endif>Select
                                </option>
                                <option value="Neck Stiffness" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Neck Stiffness') || old('Fever') == 'Neck Stiffness') selected @endif>Neck
                                    Stiffness</option>
                                <option
                                    value="Neck stiffness, especially when trying to touch the chin to the chest (neck flexion)"
                                    @if (
                                        (!empty($Meningitis) &&
                                            $Meningitis['Fever'] ==
                                                'Neck stiffness, especially when trying to touch the chin to the chest (neck flexion)') ||
                                            old('Fever') == 'Neck stiffness, especially when trying to touch the chin to the chest (neck flexion)') selected @endif>Neck stiffness, especially when
                                    trying to touch the chin to the chest (neck flexion)</option>
                                <option value="Altered Mental Status"
                                    @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Altered Mental Status') || old('Fever') == 'Altered Mental Status') selected @endif>Altered Mental Status</option>
                                <option value="Nausea and Vomiting" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Nausea and Vomiting') || old('Fever') == 'Nausea and Vomiting') selected @endif>
                                    Nausea and Vomiting</option>
                                <option value="Photophobia" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Photophobia') || old('Fever') == 'Photophobia') selected @endif>
                                    Photophobia</option>
                                <option value="Rash" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Rash') || old('Fever') == 'Rash') selected @endif>Rash</option>
                                <option value="Recent Infection" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'Recent Infection') || old('Fever') == 'Recent Infection') selected @endif>
                                    Recent Infection</option>
                                <option value="Recent exposure to someone with meningitis or a known outbreak"
                                    @if (
                                        (!empty($Meningitis) && $Meningitis['Fever'] == 'Recent exposure to someone with meningitis or a known outbreak') ||
                                            old('Fever') == 'Recent exposure to someone with meningitis or a known outbreak') selected @endif>Recent exposure to someone with
                                    meningitis or a known outbreak</option>
                                <option value="Incomplete or lack of vaccination against bacterial causes of meningitis"
                                    @if (
                                        (!empty($Meningitis) &&
                                            $Meningitis['Fever'] == 'Incomplete or lack of vaccination against bacterial causes of meningitis') ||
                                            old('Fever') == 'Incomplete or lack of vaccination against bacterial causes of meningitis') selected @endif>Incomplete or lack of vaccination
                                    against bacterial causes of meningitis</option>
                                <option value="none" @if ((!empty($Meningitis) && $Meningitis['Fever'] == 'none') || old('Fever') == 'none') selected @endif>none</option>
                            </select>

                        </div>
                    </div>


                </div>

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            </div>


            <div class="step " id="step7">
                <h3>Abdominal Pain History</h3>
                <div class="form-row">
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="location_of_pain">Location of Pain</label>


                            <select class="form-control" id="location_of_pain" name="location_of_pain" required>
                                <option value="" @if (empty($AbdominalPainHistory['LocationOfPain']) && !old('location_of_pain')) selected @endif>Select
                                </option>
                                <option value="Upper abdomen (epigastric)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Upper abdomen (epigastric)') ||
                                            old('location_of_pain') == 'Upper abdomen (epigastric)') selected @endif>Upper abdomen (epigastric)
                                </option>
                                <option value="Lower abdomen (hypogastric)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Lower abdomen (hypogastric)') ||
                                            old('location_of_pain') == 'Lower abdomen (hypogastric)') selected @endif>Lower abdomen (hypogastric)
                                </option>
                                <option value="Right upper quadrant (RUQ)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Right upper quadrant (RUQ)') ||
                                            old('location_of_pain') == 'Right upper quadrant (RUQ)') selected @endif>Right upper quadrant (RUQ)
                                </option>
                                <option value="Left upper quadrant (LUQ)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Left upper quadrant (LUQ)') ||
                                            old('location_of_pain') == 'Left upper quadrant (LUQ)') selected @endif>Left upper quadrant (LUQ)</option>
                                <option value="Right lower quadrant (RLQ)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Right lower quadrant (RLQ)') ||
                                            old('location_of_pain') == 'Right lower quadrant (RLQ)') selected @endif>Right lower quadrant (RLQ)
                                </option>
                                <option value="Left lower quadrant (LLQ)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'Left lower quadrant (LLQ)') ||
                                            old('location_of_pain') == 'Left lower quadrant (LLQ)') selected @endif>Left lower quadrant (LLQ)</option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['LocationOfPain'] == 'none') ||
                                        old('location_of_pain') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="character_of_pain">Character of Pain</label>



                            <select class="form-control" id="character_of_pain" name="character_of_pain" required>
                                <option value="" @if (empty(!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain']) && !old('character_of_pain')) selected @endif>Select
                                </option>
                                <option value="Sharp" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'Sharp') ||
                                        old('character_of_pain') == 'Sharp') selected @endif>Sharp</option>
                                <option value="Dull" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'Dull') ||
                                        old('character_of_pain') == 'Dull') selected @endif>Dull</option>
                                <option value="Burning" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'Burning') ||
                                        old('character_of_pain') == 'Burning') selected @endif>Burning
                                </option>
                                <option value="Cramping" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'Cramping') ||
                                        old('character_of_pain') == 'Cramping') selected @endif>Cramping
                                </option>
                                <option value="Colicky (waves of intense pain)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'Colicky (waves of intense pain)') ||
                                            old('character_of_pain') == 'Colicky (waves of intense pain)') selected @endif>Colicky (waves of intense pain)
                                </option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['CharacterOfPain'] == 'none') ||
                                        old('character_of_pain') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="onset_and_duration">Onset and Duration</label>

                            <select class="form-control" id="onset_and_duration" name="onset_and_duration" required>
                                <option value="" @if (empty($AbdominalPainHistory['OnsetAndDuration']) && !old('onset_and_duration')) selected @endif>Select
                                </option>
                                <option value="Sudden onset" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'Sudden onset') ||
                                        old('onset_and_duration') == 'Sudden onset') selected @endif>Sudden
                                    onset</option>
                                <option value="Gradual onset" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'Gradual onset') ||
                                        old('onset_and_duration') == 'Gradual onset') selected @endif>Gradual
                                    onset</option>
                                <option value="Constant" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'Constant') ||
                                        old('onset_and_duration') == 'Constant') selected @endif>Constant
                                </option>
                                <option value="Intermittent" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'Intermittent') ||
                                        old('onset_and_duration') == 'Intermittent') selected @endif>
                                    Intermittent</option>
                                <option value="Duration of pain episodes"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'Duration of pain episodes') ||
                                            old('onset_and_duration') == 'Duration of pain episodes') selected @endif>Duration of pain episodes</option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['OnsetAndDuration'] == 'none') ||
                                        old('onset_and_duration') == 'none') selected @endif>none</option>
                            </select>


                        </div>
                    </div>


                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="relieving_factors">Aggravating or Relieving Factors</label>



                            <select class="form-control" id="relieving_factors" name="relieving_factors" required>
                                <option value="" @if (empty($AbdominalPainHistory['AggravatingOrRelieving']) && !old('relieving_factors')) selected @endif>Select
                                </option>
                                <option value="Aggravated by eating" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AggravatingOrRelieving'] == 'Aggravated by eating') ||
                                        old('relieving_factors') == 'Aggravated by eating') selected @endif>
                                    Aggravated by eating</option>
                                <option value="Relieved by eating" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AggravatingOrRelieving'] == 'Relieved by eating') ||
                                        old('relieving_factors') == 'Relieved by eating') selected @endif>
                                    Relieved by eating</option>
                                <option value="Aggravated by movement or certain positions"
                                    @if (
                                        (!empty($AbdominalPainHistory) &&
                                            $AbdominalPainHistory['AggravatingOrRelieving'] == 'Aggravated by movement or certain positions') ||
                                            old('relieving_factors') == 'Aggravated by movement or certain positions') selected @endif>Aggravated by movement or certain
                                    positions</option>
                                <option value="Relieved by rest or specific positions"
                                    @if (
                                        (!empty($AbdominalPainHistory) &&
                                            $AbdominalPainHistory['AggravatingOrRelieving'] == 'Relieved by rest or specific positions') ||
                                            old('relieving_factors') == 'Relieved by rest or specific positions') selected @endif>Relieved by rest or specific
                                    positions</option>
                                <option value="Aggravated by certain foods or drinks"
                                    @if (
                                        (!empty($AbdominalPainHistory) &&
                                            $AbdominalPainHistory['AggravatingOrRelieving'] == 'Aggravated by certain foods or drinks') ||
                                            old('relieving_factors') == 'Aggravated by certain foods or drinks') selected @endif>Aggravated by certain foods or
                                    drinks</option>
                                <option value="Associated with bowel movements or urination"
                                    @if (
                                        (!empty($AbdominalPainHistory) &&
                                            $AbdominalPainHistory['AggravatingOrRelieving'] == 'Associated with bowel movements or urination') ||
                                            old('relieving_factors') == 'Associated with bowel movements or urination') selected @endif>Associated with bowel movements or
                                    urination</option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AggravatingOrRelieving'] == 'none') ||
                                        old('relieving_factors') == 'none') selected @endif>none</option>
                            </select>


                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="associated_symptoms">Associated Symptoms</label>


                            <select class="form-control" id="associated_symptoms" name="associated_symptoms" required>
                                <option value="" @if (empty($AbdominalPainHistory['AssociatedSymptoms']) && !old('associated_symptoms')) selected @endif>Select
                                </option>
                                <option value="Nausea" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Nausea') ||
                                        old('associated_symptoms') == 'Nausea') selected @endif>Nausea
                                </option>
                                <option value="Vomiting" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Vomiting') ||
                                        old('associated_symptoms') == 'Vomiting') selected @endif>Vomiting
                                </option>
                                <option value="Diarrhea" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Diarrhea') ||
                                        old('associated_symptoms') == 'Diarrhea') selected @endif>Diarrhea
                                </option>
                                <option value="Constipation" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Constipation') ||
                                        old('associated_symptoms') == 'Constipation') selected @endif>
                                    Constipation</option>
                                <option value="Fever" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Fever') ||
                                        old('associated_symptoms') == 'Fever') selected @endif>Fever</option>
                                <option value="Bloating" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Bloating') ||
                                        old('associated_symptoms') == 'Bloating') selected @endif>Bloating
                                </option>
                                <option value="Changes in appetite or weight"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Changes in appetite or weight') ||
                                            old('associated_symptoms') == 'Changes in appetite or weight') selected @endif>Changes in appetite or weight
                                </option>
                                <option value="Blood in stool" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Blood in stool') ||
                                        old('associated_symptoms') == 'Blood in stool') selected @endif>Blood
                                    in stool</option>
                                <option value="Blood in vomit" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'Blood in vomit') ||
                                        old('associated_symptoms') == 'Blood in vomit') selected @endif>Blood
                                    in vomit</option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['AssociatedSymptoms'] == 'none') ||
                                        old('associated_symptoms') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="medical_history">Medical History</label>


                            <select class="form-control" id="medical_history" name="medical_history" required>
                                <option value="" @if (empty($AbdominalPainHistory['MedicalHistory']) && !old('medical_history')) selected @endif>Select
                                </option>
                                <option value="Previous Episodes" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'Previous Episodes') ||
                                        old('medical_history') == 'Previous Episodes') selected @endif>
                                    Previous Episodes</option>
                                <option value="Digestive Disorders" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'Digestive Disorders') ||
                                        old('medical_history') == 'Digestive Disorders') selected @endif>
                                    Digestive Disorders</option>
                                <option value="Gallstones/Kidney Stones(known)"
                                    @if (
                                        (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'Gallstones/Kidney Stones(known)') ||
                                            old('medical_history') == 'Gallstones/Kidney Stones(known)') selected @endif>Gallstones/Kidney Stones(known)
                                </option>
                                <option value="Dietary Changes" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'Dietary Changes') ||
                                        old('medical_history') == 'Dietary Changes') selected @endif>
                                    Dietary Changes</option>
                                <option value="Travel History" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'Travel History') ||
                                        old('medical_history') == 'Travel History') selected @endif>Travel
                                    History</option>
                                <option value="none" @if (
                                    (!empty($AbdominalPainHistory) && $AbdominalPainHistory['MedicalHistory'] == 'none') ||
                                        old('medical_history') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6" id="previous_episode"
                        @if (!empty($AbdominalPainHistory['previous_episodes'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="previous_episodes">Previous Episodes</label>
                            <input type="text" class="form-control" name="previous_episodes"
                                @if (!empty($AbdominalPainHistory['previous_episodes'])) value="{{ $AbdominalPainHistory['previous_episodes'] }}"
                            @else
                            value="{{ old('previous_episodes') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6" id="digestive_disorder"
                        @if (!empty($AbdominalPainHistory['digestive_disorders'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="digestive_disorders">Digestive Disorders:if diagnosed</label>
                            <input type="text" class="form-control" name="digestive_disorders"
                                @if (!empty($AbdominalPainHistory['digestive_disorders'])) value="{{ $AbdominalPainHistory['digestive_disorders'] }}"
                            @else
                            value="{{ old('digestive_disorders') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6" id="dietary_changes_time"
                        @if (!empty($AbdominalPainHistory['dietary_changes_times'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="dietary_changes_times">Dietary Changes:timing</label>
                            <input type="text" class="form-control" name="dietary_changes_times"
                                @if (!empty($AbdominalPainHistory['dietary_changes_times'])) value="{{ $AbdominalPainHistory['dietary_changes_times'] }}"
                            @else
                            value="{{ old('dietary_changes_times') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6" id="dietary_changes_routine"
                        @if (!empty($AbdominalPainHistory['dietary_changes_routines'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="dietary_changes_routines">Dietary Changes:routine</label>
                            <input type="text" class="form-control" name="dietary_changes_routines"
                                @if (!empty($AbdominalPainHistory['dietary_changes_routines'])) value="{{ $AbdominalPainHistory['dietary_changes_routines'] }}"
                            @else
                            value="{{ old('dietary_changes_routines') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6" id="travel_history"
                        @if (!empty($AbdominalPainHistory['travel_historys'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="travel_historys">Travel History</label>
                            <input type="text" class="form-control" name="travel_historys"
                                @if (!empty($AbdominalPainHistory['travel_historys'])) value="{{ $AbdominalPainHistory['travel_historys'] }}"
                            @else
                            value="{{ old('travel_historys') }}" @endif>
                        </div>
                    </div>
                    <h6 class="w-100">
                        Personal History
                    </h6>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lifestyle_habits">Lifestyle Habits</label>



                            <select class="form-control" id="lifestyle_habits" name="lifestyle_habits" required>
                                <option value="" @if (empty($PersonalHistory['LifestyleHabits']) && !old('lifestyle_habits')) selected @endif>Select
                                </option>
                                <option value="Smoking" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Smoking') ||
                                        old('lifestyle_habits') == 'Smoking') selected @endif>Smoking
                                </option>
                                <option value="Exercise" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Exercise') ||
                                        old('lifestyle_habits') == 'Exercise') selected @endif>Exercise
                                </option>
                                <option value="Current Medications" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Current Medications') ||
                                        old('lifestyle_habits') == 'Current Medications') selected @endif>
                                    Current Medications</option>
                                <option value="Weight lifting" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Weight lifting') ||
                                        old('lifestyle_habits') == 'Weight lifting') selected @endif>Weight
                                    lifting</option>
                                <option value="Home chores" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Home chores') ||
                                        old('lifestyle_habits') == 'Home chores') selected @endif>Home
                                    chores</option>
                                <option value="Sports" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Sports') ||
                                        old('lifestyle_habits') == 'Sports') selected @endif>Sports
                                </option>
                                <option value="Homework and studies" @if (
                                    (!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'Homework and studies') ||
                                        old('lifestyle_habits') == 'Homework and studies') selected @endif>
                                    Homework and studies</option>
                                <option value="none" @if ((!empty($PersonalHistory) && $PersonalHistory['LifestyleHabits'] == 'none') || old('lifestyle_habits') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6" id="current_medication"
                        @if (!empty($PersonalHistory['CurrentMedications'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="current_medications">Current Medications</label>
                            <input type="text" class="form-control" name="current_medications"
                                @if (!empty($PersonalHistory['CurrentMedications'])) value="{{ $PersonalHistory['CurrentMedications'] }}"
                            @else
                            value="{{ old('current_medications') }}" @endif>
                        </div>
                    </div>
                    <div class="form-group col-md-6" id="sport"
                        @if (!empty($PersonalHistory['sports'])) @else

                    style="display:none" @endif>
                        <div class="form-group">
                            <label for="sports">Sports</label>
                            <input type="text" class="form-control" name="sports"
                                @if (!empty($PersonalHistory['sports'])) value="{{ $PersonalHistory['sports'] }}"
                            @else
                            value="{{ old('sports') }}" @endif>



                        </div>
                    </div>


                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>

            <div class="step  " id="step8">
                <h3>Sleep Routine</h3>
                <div class="form-row">

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="bed_time">Bed time</label>
                            <input type="text" class="form-control" id="bed_time" name="bed_time"
                                @if (!empty($SleepRoutine['BedTime'])) value="{{ $SleepRoutine['BedTime'] }}"
                            @else
                            value="{{ old('bed_time') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sleep_duration">Sleep duration</label>
                            <input type="text" class="form-control" id="sleep_duration" name="sleep_duration"
                                @if (!empty($SleepRoutine['SleepDuration'])) value="{{ $SleepRoutine['SleepDuration'] }}"
                            @else
                            value="{{ old('bed_time') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sleep_quality">Sleep quality</label>



                            <select class="form-control" id="sleep_quality" name="sleep_quality" required>
                                <option value="" @if (empty($SleepRoutine['SleepQuality']) && !old('sleep_quality')) selected @endif>Select
                                </option>
                                <option value="1" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '1') || old('sleep_quality') == '1') selected @endif>1</option>
                                <option value="2" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '2') || old('sleep_quality') == '2') selected @endif>2</option>
                                <option value="3" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '3') || old('sleep_quality') == '3') selected @endif>3</option>
                                <option value="4" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '4') || old('sleep_quality') == '4') selected @endif>4</option>
                                <option value="5" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '5') || old('sleep_quality') == '5') selected @endif>5</option>
                                <option value="6" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '6') || old('sleep_quality') == '6') selected @endif>6</option>
                                <option value="7" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '7') || old('sleep_quality') == '7') selected @endif>7</option>
                                <option value="8" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '8') || old('sleep_quality') == '8') selected @endif>8</option>
                                <option value="9" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '9') || old('sleep_quality') == '9') selected @endif>9</option>
                                <option value="10" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == '10') || old('sleep_quality') == '10') selected @endif>10</option>
                                <option value="none" @if ((!empty($SleepRoutine) && $SleepRoutine['SleepQuality'] == 'none') || old('sleep_quality') == 'none') selected @endif>none</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="bedtime_routine">Bedtime routine</label>
                            <input type="text" class="form-control" id="bedtime_routine" name="bedtime_routine"
                                @if (!empty($SleepRoutine['BedtimeRoutine'])) value="{{ $SleepRoutine['BedtimeRoutine'] }}"
                            @else
                            value="{{ old('bedtime_routine') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="daytime_naps">Daytime naps</label>
                            <input type="text" class="form-control" id="daytime_naps" name="daytime_naps"
                                @if (!empty($SleepRoutine['DaytimeNaps'])) value="{{ $SleepRoutine['DaytimeNaps'] }}"
                            @else
                            value="{{ old('daytime_naps') }}" @endif
                                required>


                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="breathing_difficulties">Snoring or breathing difficulties</label>
                            <input type="text" class="form-control" id="breathing_difficulties"
                                name="breathing_difficulties"
                                @if (!empty($SleepRoutine['SnoringOrBreathing'])) value="{{ $SleepRoutine['SnoringOrBreathing'] }}"
                                @else
                                value="{{ old('breathing_difficulties') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="restlessness_sleep">Restlessness during sleep</label>
                            <input type="text" class="form-control" id="restlessness_sleep" name="restlessness_sleep"
                                @if (!empty($SleepRoutine['RestlessnessDuringSleep'])) value="{{ $SleepRoutine['RestlessnessDuringSleep'] }}"
                            @else
                            value="{{ old('restlessness_sleep') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sleep_environment">Sleep environment (noise, light, etc.)</label>
                            <input type="text" class="form-control" id="sleep_environment" name="sleep_environment"
                                @if (!empty($SleepRoutine['SleepEnvironment'])) value="{{ $SleepRoutine['SleepEnvironment'] }}"
                            @else
                            value="{{ old('sleep_environment') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sleep_related_behaviors">Sleep-related behaviors (sleepwalking, teeth grinding,
                                etc.)</label>
                            <input type="text" class="form-control" id="sleep_related_behaviors"
                                name="sleep_related_behaviors"
                                @if (!empty($SleepRoutine['SleepRelatedBehaviors'])) value="{{ $SleepRoutine['SleepRelatedBehaviors'] }}"
                                @else
                                value="{{ old('sleep_related_behaviors') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="medical_conditions_affecting">Medical conditions affecting sleep</label>
                            <input type="text" class="form-control" id="medical_conditions_affecting"
                                name="medical_conditions_affecting"
                                @if (!empty($SleepRoutine['AffectingSleep'])) value="{{ $SleepRoutine['AffectingSleep'] }}"
                                @else
                                value="{{ old('medical_conditions_affecting') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="medications_impacting_sleep">Medications impacting sleep</label>
                            <input type="text" class="form-control" id="medications_impacting_sleep"
                                name="medications_impacting_sleep"
                                @if (!empty($SleepRoutine['ImpactingSleep'])) value="{{ $SleepRoutine['ImpactingSleep'] }}"
                                @else
                                value="{{ old('medications_impacting_sleep') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="enuresis">Enuresis</label>
                            <input type="text" class="form-control" id="enuresis" name="enuresis"
                                @if (!empty($SleepRoutine['Enuresis'])) value="{{ $SleepRoutine['Enuresis'] }}"
                            @else
                            value="{{ old('enuresis') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="immunization_history">Immunization history</label>
                            <input type="text" class="form-control" id="immunization_history"
                                name="immunization_history"
                                @if (!empty($SleepRoutine['ImmunizationHistory'])) value="{{ $SleepRoutine['ImmunizationHistory'] }}"
                                @else
                                value="{{ old('immunization_history') }}" @endif
                                required>
                        </div>
                    </div>



                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>

            <div class="step " id="step9">
                <h3>Nutrition History</h3>
                <div class="form-row">

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="breakfast">Breakfast if yes</label>
                            <input type="text" class="form-control" id="breakfast" name="breakfast"
                                @if (!empty($NutritionHistory['BreakfastIfYes'])) value="{{ $NutritionHistory['BreakfastIfYes'] }}"
                            @else
                            value="{{ old('breakfast') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="roti_eat">How much roti did they eat?</label>
                            <input type="text" class="form-control" id="roti_eat" name="roti_eat"
                                @if (!empty($NutritionHistory['RotiTheyEat'])) value="{{ $NutritionHistory['RotiTheyEat'] }}"
                            @else
                            value="{{ old('roti_eat') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lunch">Lunch</label>
                            <input type="text" class="form-control" id="lunch" name="lunch"
                                @if (!empty($NutritionHistory['Lunch'])) value="{{ $NutritionHistory['Lunch'] }}"
                            @else
                            value="{{ old('lunch') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="skip_meal">Skip meals</label>
                            <input type="text" class="form-control" id="skip_meal" name="skip_meal"
                                @if (!empty($NutritionHistory['SkipMeals'])) value="{{ $NutritionHistory['SkipMeals'] }}"
                            @else
                            value="{{ old('skip_meal') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="meal_preference">Meal preferences especially dislikes</label>
                            <input type="text" class="form-control" id="meal_preference" name="meal_preference"
                                @if (!empty($NutritionHistory['MealPreferences'])) value="{{ $NutritionHistory['MealPreferences'] }}"
                            @else
                            value="{{ old('meal_preference') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="food_allergies">Food allergies</label>
                            <input type="text" class="form-control" id="food_allergies" name="food_allergies"
                                @if (!empty($NutritionHistory['FoodAllergies'])) value="{{ $NutritionHistory['FoodAllergies'] }}"
                            @else
                            value="{{ old('food_allergies') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="dietary_restrictions">Dietary restrictions</label>
                            <input type="text" class="form-control" id="dietary_restrictions"
                                name="dietary_restrictions"
                                @if (!empty($NutritionHistory['DietaryRestrictions'])) value="{{ $NutritionHistory['DietaryRestrictions'] }}"
                                @else
                                value="{{ old('dietary_restrictions') }}" @endif
                                required>
                        </div>
                    </div>



                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>



            <div class="step  " id="step10">
                <h3>Medical History</h3>
                <h4 class="w-100">
                    Cardiovascular System:
                </h4>
                <h6 class="w-100">
                    Chest pain
                </h6>
                <div class="form-row">

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="onset">Onset</label>
                            <input type="text" class="form-control" id="onset" name="onset"
                                @if (!empty($ChestPain['Onset'])) value="{{ $ChestPain['Onset'] }}"
                                @else
                                value="{{ old('onset') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="duration">Duration</label>
                            <input type="text" class="form-control" id="duration" name="duration"
                                @if (!empty($ChestPain['Duration'])) value="{{ $ChestPain['Duration'] }}"
                            @else
                            value="{{ old('duration') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="severity">Severity</label>



                            <select class="form-control" id="severity" name="severity" required>
                                <option value="" @if (empty($ChestPain['Severity']) && !old('severity')) selected @endif>Select
                                </option>
                                <option value="1" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '1') || old('severity') == '1') selected @endif>1</option>
                                <option value="2" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '2') || old('severity') == '2') selected @endif>2</option>
                                <option value="3" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '3') || old('severity') == '3') selected @endif>3</option>
                                <option value="4" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '4') || old('severity') == '4') selected @endif>4</option>
                                <option value="5" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '5') || old('severity') == '5') selected @endif>5</option>
                                <option value="6" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '6') || old('severity') == '6') selected @endif>6</option>
                                <option value="7" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '7') || old('severity') == '7') selected @endif>7</option>
                                <option value="8" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '8') || old('severity') == '8') selected @endif>8</option>
                                <option value="9" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '9') || old('severity') == '9') selected @endif>9</option>
                                <option value="10" @if ((!empty($ChestPain) && $ChestPain['Severity'] == '10') || old('severity') == '10') selected @endif>10</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="location">location</label>
                            <input type="text" class="form-control" id="location" name="location"
                                @if (!empty($ChestPain['Location'])) value="{{ $ChestPain['Location'] }}"
                            @else
                            value="{{ old('location') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="palpitations">Palpitations</label>
                            <input type="text" class="form-control" id="palpitations" name="palpitations"
                                @if (!empty($ChestPain['Palpitations'])) value="{{ $ChestPain['Palpitations'] }}"
                            @else
                            value="{{ old('palpitations') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="fainting_syncope">Fainting/syncope</label>
                            <input type="text" class="form-control" id="fainting_syncope" name="fainting_syncope"
                                @if (!empty($ChestPain['FaintingSyncope'])) value="{{ $ChestPain['FaintingSyncope'] }}"
                            @else
                            value="{{ old('fainting_syncope') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="cyanosis">Cyanosis</label>
                            <input type="text" class="form-control" id="cyanosis" name="cyanosis"
                                @if (!empty($ChestPain['Cyanosis'])) value="{{ $ChestPain['Cyanosis'] }}"
                            @else
                            value="{{ old('cyanosis') }}" @endif
                                required>
                        </div>
                    </div>
                    <h5 class="w-100">Sob</h5>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="on_exertion">on exertion</label>
                            <input type="text" class="form-control" id="on_exertion" name="on_exertion"
                                @if (!empty($Sob['OnExertion'])) value="{{ $Sob['OnExertion'] }}"
                            @else
                            value="{{ old('on_exertion') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="on_rest">on rest</label>
                            <input type="text" class="form-control" id="on_rest" name="on_rest"
                                @if (!empty($Sob['OnRst'])) value="{{ $Sob['OnRst'] }}"
                            @else
                            value="{{ old('on_rest') }}" @endif
                                required>
                        </div>
                    </div>
                    <h5 class="w-100">Respiratory System</h5>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="nasal_patency">Nasal patency</label>
                            <input type="text" class="form-control" id="nasal_patency" name="nasal_patency"
                                @if (!empty($RespiratorySystem['NasalPatency'])) value="{{ $RespiratorySystem['NasalPatency'] }}"
                            @else
                            value="{{ old('nasal_patency') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="clubbing">Clubbing</label>
                            <input type="text" class="form-control" id="clubbing" name="clubbing"
                                @if (!empty($RespiratorySystem['Clubbing'])) value="{{ $RespiratorySystem['Clubbing'] }}"
                            @else
                            value="{{ old('clubbing') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="asthma">Asthma</label>
                            <input type="text" class="form-control" id="asthma" name="asthma"
                                @if (!empty($RespiratorySystem['Asthma'])) value="{{ $RespiratorySystem['Asthma'] }}"
                            @else
                            value="{{ old('asthma') }}" @endif
                                required>
                        </div>
                    </div>
                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>



            <div class="step " id="step11">
                <h3>Upper Resp</h3>
                <div class="form-row">

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sore_throat">Sore throat</label>
                            <input type="text" class="form-control" id="sore_throat" name="sore_throat"
                                @if (!empty($UpperResp['SoreThroat'])) value="{{ $UpperResp['SoreThroat'] }}"
                            @else
                            value="{{ old('sore_throat') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="ear_ache">Ear Ache</label>
                            <input type="text" class="form-control" id="ear_ache" name="ear_ache"
                                @if (!empty($UpperResp['EarAche'])) value="{{ $UpperResp['EarAche'] }}"
                            @else
                            value="{{ old('ear_ache') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="ear_discharge">Ear discharge</label>


                            <select class="form-control" id="ear_discharge" name="ear_discharge" required>
                                <option value="" @if (empty($UpperResp['EarDischarge']) && !old('ear_discharge')) selected @endif>Select
                                </option>
                                <option value="White" @if ((!empty($UpperResp) && $UpperResp['EarDischarge'] == 'White') || old('ear_discharge') == 'White') selected @endif>White</option>
                                <option value="Pussy" @if ((!empty($UpperResp) && $UpperResp['EarDischarge'] == 'Pussy') || old('ear_discharge') == 'Pussy') selected @endif>Pussy</option>
                                <option value="odour" @if ((!empty($UpperResp) && $UpperResp['EarDischarge'] == 'odour') || old('ear_discharge') == 'odour') selected @endif>odour</option>
                            </select>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="runny_nose">Runny nose</label>
                            <input type="text" class="form-control" id="runny_nose" name="runny_nose"
                                @if (!empty($UpperResp['RunnyNse'])) value="{{ $UpperResp['RunnyNse'] }}"
                            @else
                            value="{{ old('runny_nose') }}" @endif
                                required>
                        </div>
                    </div>
                    <h6 class="w-100">Cough</h6>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sputum_color">Sputum color</label>
                            <input type="text" class="form-control" id="sputum_color" name="sputum_color"
                                @if (!empty($Cough['SputumColor'])) value="{{ $Cough['SputumColor'] }}"
                            @else
                            value="{{ old('sputum_color') }}" @endif
                                required>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="sputum_quantity">Sputum quantity</label>
                            <input type="text" class="form-control" id="sputum_quantity" name="sputum_quantity"
                                @if (!empty($Cough['SputumQuantity'])) value="{{ $Cough['SputumQuantity'] }}"
                            @else
                            value="{{ old('sputum_quantity') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="Brasky">Brasky</label>
                            <input type="text" class="form-control" id="Brasky" name="Brasky"
                                @if (!empty($Cough['Brasky'])) value="{{ $Cough['Brasky'] }}"
                            @else
                            value="{{ old('Brasky') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="whooping">Whooping</label>
                            <input type="text" class="form-control" id="whooping" name="whooping"
                                @if (!empty($Cough['Whooping'])) value="{{ $Cough['Whooping'] }}"
                            @else
                            value="{{ old('whooping') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="blood_in_sputum">Blood in sputum</label>
                            <input type="text" class="form-control" id="blood_in_sputum" name="blood_in_sputum"
                                @if (!empty($Cough['BloodInSputum'])) value="{{ $Cough['BloodInSputum'] }}"
                            @else
                            value="{{ old('blood_in_sputum') }}" @endif
                                required>
                        </div>
                    </div>

                    <h4 class="w-100">
                        History of Pneumonia
                    </h4>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="episode_per_month">Episodes per month</label>
                            <input type="text" class="form-control" id="episode_per_month" name="episode_per_month"
                                @if (!empty($HistoryOfPneumonia['EpisodesPerMonth'])) value="{{ $HistoryOfPneumonia['EpisodesPerMonth'] }}"
                            @else
                            value="{{ old('episode_per_month') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="hospitalization">Hospitalization</label>
                            <input type="text" class="form-control" id="hospitalization" name="hospitalization"
                                @if (!empty($HistoryOfPneumonia['Hospitalization'])) value="{{ $HistoryOfPneumonia['Hospitalization'] }}"
                            @else
                            value="{{ old('hospitalization') }}" @endif
                                required>
                        </div>
                    </div>
                </div>

                <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
                <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
            </div>


            <div class="step " id="step12">
                <h3>Lower Respiratory tract infections</h3>
                <div class="form-row">

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lower_sputum_color">Sputum color</label>
                            <input type="text" class="form-control" id="lower_sputum_color"
                                name="lower_sputum_color"
                                @if (!empty($LowerRespiratoryTractInfections['SputumColor'])) value="{{ $LowerRespiratoryTractInfections['SputumColor'] }}"
                            @else
                            value="{{ old('lower_sputum_color') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lower_speutum_quantitiy">Sputum quantity</label>
                            <input type="text" class="form-control" id="lower_speutum_quantitiy"
                                name="lower_speutum_quantitiy"
                                @if (!empty($LowerRespiratoryTractInfections['SputumQuantity'])) value="{{ $LowerRespiratoryTractInfections['SputumQuantity'] }}"
                                @else
                                value="{{ old('lower_speutum_quantitiy') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lower_brasky">Brasky</label>
                            <input type="text" class="form-control" id="lower_brasky" name="lower_brasky"
                                @if (!empty($LowerRespiratoryTractInfections['Brasky'])) value="{{ $LowerRespiratoryTractInfections['Brasky'] }}"
                            @else
                            value="{{ old('lower_brasky') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lower_whooping">Whooping</label>
                            <input type="text" class="form-control" id="lower_whooping" name="lower_whooping"
                                @if (!empty($LowerRespiratoryTractInfections['Whooping'])) value="{{ $LowerRespiratoryTractInfections['Whooping'] }}"
                            @else
                            value="{{ old('lower_whooping') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="lower_blood_in_sputum">Blood in sputum</label>
                            <input type="text" class="form-control" id="lower_blood_in_sputum"
                                name="lower_blood_in_sputum"
                                @if (!empty($LowerRespiratoryTractInfections['BloodInSputum'])) value="{{ $LowerRespiratoryTractInfections['BloodInSputum'] }}"
                                @else
                                value="{{ old('lower_blood_in_sputum') }}" @endif
                                required>
                        </div>
                    </div>

                    <h5 class="w-100">Sob</h5>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="on_exertion_mild">On Exertion Mild</label>
                            <input type="text" class="form-control" id="on_exertion_mild" name="on_exertion_mild"
                                @if (!empty($LowerRespiratorySob['OnExertionMild'])) value="{{ $LowerRespiratorySob['OnExertionMild'] }}"
                            @else
                            value="{{ old('on_exertion_mild') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="on_exertion_moderate">On Exertion Moderate</label>
                            <input type="text" class="form-control" id="on_exertion_moderate"
                                name="on_exertion_moderate"
                                @if (!empty($LowerRespiratorySob['OnExertionModerate'])) value="{{ $LowerRespiratorySob['OnExertionModerate'] }}"
                                @else
                                value="{{ old('on_exertion_moderate') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="on_exertion_severe">On Exertion Severe</label>
                            <input type="text" class="form-control" id="on_exertion_severe"
                                name="on_exertion_severe"
                                @if (!empty($LowerRespiratorySob['OnExertionSevere'])) value="{{ $LowerRespiratorySob['OnExertionSevere'] }}"
                                @else
                                value="{{ old('on_exertion_severe') }}" @endif
                                required>
                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="wheezing">Wheezing</label>
                            <input type="text" class="form-control" id="wheezing" name="wheezing"
                                @if (!empty($LowerRespiratorySob['Wheezing'])) value="{{ $LowerRespiratorySob['Wheezing'] }}"
                            @else
                            value="{{ old('wheezing') }}" @endif
                                required>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="crackles">Crackles</label>
                            <input type="text" class="form-control" id="crackles" name="crackles"
                                @if (!empty($LowerRespiratorySob['Crackles'])) value="{{ $LowerRespiratorySob['Crackles'] }}"
                            @else
                            value="{{ old('crackles') }}" @endif
                                required>




                        </div>
                    </div>
                    <h5 class="w-100">History of Infections</h5>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="infection_episodes_per_month">Episodes per month</label>
                            <input type="text" class="form-control" id="infection_episodes_per_month"
                                name="infection_episodes_per_month"
                                @if (!empty($HistoryOfInfection['EpisodesPerMonth'])) value="{{ $HistoryOfInfection['EpisodesPerMonth'] }}"
                            @else
                            value="{{ old('infection_episodes_per_month') }}" @endif
                                required>



                        </div>
                    </div>
                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="hospitalisation">Hospitalisation</label>
                            <input type="text" class="form-control" id="hospitalisation" name="hospitalisation"
                                @if (!empty($HistoryOfInfection['Hospitalisation'])) value="{{ $HistoryOfInfection['Hospitalisation'] }}"
                            @else
                            value="{{ old('hospitalisation') }}" @endif
                                required>
                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="gastrointestinal_system">Gastrointestinal System</label>


                            <select class="form-control" id="gastrointestinal_system" name="gastrointestinal_system"
                                required>
                                <option value="" @if (empty($HistoryOfInfection['GastrointestinalSystem']) && !old('gastrointestinal_system')) selected @endif>Select
                                </option>
                                <option value="GERD" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'GERD') ||
                                        old('gastrointestinal_system') == 'GERD') selected @endif>GERD</option>
                                <option value="Blood in stool" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Blood in stool') ||
                                        old('gastrointestinal_system') == 'Blood in stool') selected @endif>Blood
                                    in stool</option>
                                <option value="Blood in vomiting" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Blood in vomiting') ||
                                        old('gastrointestinal_system') == 'Blood in vomiting') selected @endif>
                                    Blood in vomiting</option>
                                <option value="Black tarry stools" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Black tarry stools') ||
                                        old('gastrointestinal_system') == 'Black tarry stools') selected @endif>
                                    Black tarry stools</option>
                                <option value="Distension" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Distension') ||
                                        old('gastrointestinal_system') == 'Distension') selected @endif>
                                    Distension</option>
                                <option value="Abdominal Tenderness"
                                    @if (
                                        (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Abdominal Tenderness') ||
                                            old('gastrointestinal_system') == 'Abdominal Tenderness') selected @endif>Abdominal Tenderness</option>
                                <option value="Abdominal pain" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Abdominal pain') ||
                                        old('gastrointestinal_system') == 'Abdominal pain') selected @endif>
                                    Abdominal pain</option>
                                <option value="jaundice / skin itching"
                                    @if (
                                        (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'jaundice / skin itching') ||
                                            old('gastrointestinal_system') == 'jaundice / skin itching') selected @endif>jaundice / skin itching</option>
                                <option value="Diarrhoea" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['GastrointestinalSystem'] == 'Diarrhoea') ||
                                        old('gastrointestinal_system') == 'Diarrhoea') selected @endif>Diarrhoea
                                </option>
                            </select>

                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="endocrine_system">Endocrine System</label>


                            <select class="form-control" id="endocrine_system" name="endocrine_system" required>
                                <option value="" @if (empty($HistoryOfInfection['EndocrineSystem']) && !old('endocrine_system')) selected @endif>Select
                                </option>
                                <option value="Diabetes Mellitus" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['EndocrineSystem'] == 'Diabetes Mellitus') ||
                                        old('endocrine_system') == 'Diabetes Mellitus') selected @endif>
                                    Diabetes Mellitus</option>
                                <option value="Thyroid Disorders" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['EndocrineSystem'] == 'Thyroid Disorders') ||
                                        old('endocrine_system') == 'Thyroid Disorders') selected @endif>
                                    Thyroid Disorders</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6">
                        <div class="form-group">
                            <label for="renal_system">Renal System</label>

                            <select class="form-control" id="renal_system" name="renal_system" required>
                                <option value="" @if (empty($HistoryOfInfection['RenalSystem']) && !old('renal_system')) selected @endif>Select
                                </option>
                                <option value="Kidney Stones" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Kidney Stones') ||
                                        old('renal_system') == 'Kidney Stones') selected @endif>Kidney
                                    Stones</option>
                                <option value="Polyuria" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Polyuria') ||
                                        old('renal_system') == 'Polyuria') selected @endif>Polyuria
                                </option>
                                <option value="dysuria" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'dysuria') ||
                                        old('renal_system') == 'dysuria') selected @endif>dysuria
                                </option>
                                <option value="Back pain" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Back pain') ||
                                        old('renal_system') == 'Back pain') selected @endif>Back pain
                                </option>
                                <option value="Blood in urine" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Blood in urine') ||
                                        old('renal_system') == 'Blood in urine') selected @endif>Blood
                                    in urine</option>
                                <option value="Foamy urine" @if (
                                    (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Foamy urine') ||
                                        old('renal_system') == 'Foamy urine') selected @endif>Foamy
                                    urine</option>
                                <option value="Urinary Tract Infections"
                                    @if (
                                        (!empty($HistoryOfInfection) && $HistoryOfInfection['RenalSystem'] == 'Urinary Tract Infections') ||
                                            old('renal_system') == 'Urinary Tract Infections') selected @endif>Urinary Tract Infections</option>
                            </select>



                        </div>
                    </div>

                    <div class="form-group col-md-6" id="renal_kidney"
                        @if (!empty($HistoryOfInfection['KidneyStones'])) @else
                    
                    style="display:none"> @endif
                        <div class="form-group">
                        <label for="kidney_stones_case">Kidney Stones: known case</label>
                        <input type="text" class="form-control" id="kidney_stones_case" name="kidney_stones_case"
                            @if (!empty($HistoryOfInfection['KidneyStones'])) value="{{ $HistoryOfInfection['KidneyStones'] }}"
                                @else
                                value="{{ old('kidney_stones_case') }}" @endif>
                    </div>
                </div>
                <div class="form-group col-md-6" id="back_pain"
                    @if (!empty($HistoryOfInfection['BackPain'])) @else
                    
                    style="display:none"> @endif>
                    <div class="form-group">
                        <label for="back_pain_site">Back pain :site</label>
                        <input type="text" class="form-control" id="back_pain_site" name="back_pain_site"
                            @if (!empty($HistoryOfInfection['BackPain'])) value="{{ $HistoryOfInfection['BackPain'] }}"
                            @else
                            value="{{ old('back_pain_site') }}" @endif>
                    </div>
                </div>
                <div class="form-group col-md-6" id="urinary_episodes"
                    @if (!empty($HistoryOfInfection['UrinaryTractInfections'])) @else
                    
                    style="display:none"> @endif>
                    <div class="form-group">
                        <label for="urinary_tract">Urinary Tract Infections:no.of episodes in a year</label>
                        <input type="text" class="form-control" id="urinary_tract" name="urinary_tract"
                            @if (!empty($HistoryOfInfection['UrinaryTractInfections'])) value="{{ $HistoryOfInfection['UrinaryTractInfections'] }}"
                            @else
                            value="{{ old('urinary_tract') }}" @endif>



                    </div>
                </div>


                <div class="form-group col-md-6">
                    <div class="form-group">
                        <label for="neurological_system">Neurological System</label>


                        <select class="form-control" id="neurological_system" name="neurological_system" required>
                            <option value="" @if (empty($HistoryOfInfection['NeurologicalSystem']) && !old('neurological_system')) selected @endif>Select</option>
                            <option value="Seizure Disorder" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Seizure Disorder') ||
                                    old('neurological_system') == 'Seizure Disorder') selected @endif>Seizure
                                Disorder</option>
                            <option value="Migraines" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Migraines') ||
                                    old('neurological_system') == 'Migraines') selected @endif>Migraines
                            </option>
                            <option value="Falls" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Falls') ||
                                    old('neurological_system') == 'Falls') selected @endif>Falls</option>
                            <option value="Syncope" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Syncope') ||
                                    old('neurological_system') == 'Syncope') selected @endif>Syncope</option>
                            <option value="Blurr vision" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Blurr vision') ||
                                    old('neurological_system') == 'Blurr vision') selected @endif>Blurr
                                vision</option>
                            <option value="Confusion" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Confusion') ||
                                    old('neurological_system') == 'Confusion') selected @endif>Confusion
                            </option>
                            <option value="Incontinence" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Incontinence') ||
                                    old('neurological_system') == 'Incontinence') selected @endif>
                                Incontinence</option>
                            <option value="Headache" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['NeurologicalSystem'] == 'Headache') ||
                                    old('neurological_system') == 'Headache') selected @endif>Headache
                            </option>
                        </select>


                    </div>
                </div>

                <div class="form-group col-md-6" id="neuro_falls"
                    @if (!empty($HistoryOfInfection['Falls'])) @else
                                                    style="display:none" @endif>
                    <div class="form-group">
                        <label for="neuro_falls_number">Falls</label>
                        <input type="number" class="form-control" id="neuro_falls_number" name="neuro_falls_number"
                            @if (!empty($HistoryOfInfection['Falls'])) value="{{ $HistoryOfInfection['Falls'] }}"
                                @else
                                value="{{ old('neuro_falls_number') }}" @endif>



                    </div>
                </div>
                <div class="form-group col-md-6" id="neuro_syncope"
                    @if (!empty($HistoryOfInfection['Syncope'])) @else
                    style="display:none" @endif>


                    <div class="form-group">
                        <label for="Syncope">Syncope</label>
                        <input type="text" class="form-control" id="Syncope" name="Syncope"
                            @if (!empty($HistoryOfInfection['Syncope'])) value="{{ $HistoryOfInfection['Syncope'] }}"
                            @else
                            value="{{ old('Syncope') }}" @endif>



                    </div>
                </div>

                <div class="form-group col-md-6">
                    <div class="form-group">
                        <label for="musculoskeletal_system">Musculoskeletal System</label>



                        <select class="form-control" id="musculoskeletal_system" name="musculoskeletal_system"
                            required>
                            <option value="" @if (empty($HistoryOfInfection['MusculoskeletalSystem']) && !old('musculoskeletal_system')) selected @endif>Select</option>
                            <option value="Bone pain" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Bone pain') ||
                                    old('musculoskeletal_system') == 'Bone pain') selected @endif>Bone pain
                            </option>
                            <option value="Back Pain" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Back Pain') ||
                                    old('musculoskeletal_system') == 'Back Pain') selected @endif>Back Pain
                            </option>
                            <option value="Ambulatory" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Ambulatory') ||
                                    old('musculoskeletal_system') == 'Ambulatory') selected @endif>Ambulatory
                            </option>
                            <option value="Joint movement" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Joint movement') ||
                                    old('musculoskeletal_system') == 'Joint movement') selected @endif>Joint
                                movement</option>
                            <option value="Swellings" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Swellings') ||
                                    old('musculoskeletal_system') == 'Swellings') selected @endif>Swellings
                            </option>
                            <option value="Congenital deformity" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['MusculoskeletalSystem'] == 'Congenital deformity') ||
                                    old('musculoskeletal_system') == 'Congenital deformity') selected @endif>
                                Congenital deformity</option>
                        </select>



                    </div>
                </div>

                <div class="form-group col-md-6" id="muscu_body_pain"
                    @if (!empty($HistoryOfInfection['BonePainSpecify'])) @else
                  
                    style="display:none" @endif>



                    <div class="form-group">
                        <label for="muscu_body_pain_specify">Bone pain: Specify</label>
                        <input type="number" class="form-control" id="muscu_body_pain_specify"
                            name="muscu_body_pain_specify"
                            @if (!empty($HistoryOfInfection['BonePainSpecify'])) value="{{ $HistoryOfInfection['BonePainSpecify'] }}"
                                @else
                                value="{{ old('muscu_body_pain_specify') }}" @endif>
                    </div>
                </div>

                <div class="form-group col-md-6">
                    <div class="form-group">
                        <label for="hematologic_system">Hematologic System</label>



                        <select class="form-control" id="hematologic_system" name="hematologic_system" required>
                            <option value="" @if (empty($HistoryOfInfection['HematologicSystem']) && !old('hematologic_system')) selected @endif>Select</option>
                            <option value="Anemia" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['HematologicSystem'] == 'Anemia') ||
                                    old('hematologic_system') == 'Anemia') selected @endif>Anemia</option>
                            <option value="Excessive bleeding" @if (
                                (!empty($HistoryOfInfection) && $HistoryOfInfection['HematologicSystem'] == 'Excessive bleeding') ||
                                    old('hematologic_system') == 'Excessive bleeding') selected @endif>
                                Excessive bleeding</option>
                        </select>

                    </div>
                </div>
            </div>

            <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
            <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
    </div>

    <div class="step" id="step13">
        <h3>SKIN DISEASE</h3>
        <div class="form-row">
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="rashes">Rashes</label>
                    <select class="form-control" id="rashes" name="rashes" required>
                        <option value="" @if (empty($SkinDisease['Rashes']) && !old('rashes')) selected @endif>Select</option>
                        <option value="Macular" @if ((!empty($SkinDisease) && $SkinDisease['Rashes'] == 'Macular') || old('rashes') == 'Macular') selected @endif>Macular</option>
                        <option value="papules" @if ((!empty($SkinDisease) && $SkinDisease['Rashes'] == 'papules') || old('rashes') == 'papules') selected @endif>papules</option>
                        <option value="vesicular" @if ((!empty($SkinDisease) && $SkinDisease['Rashes'] == 'vesicular') || old('rashes') == 'vesicular') selected @endif>vesicular</option>
                        <option value="Painful" @if ((!empty($SkinDisease) && $SkinDisease['Rashes'] == 'Painful') || old('rashes') == 'Painful') selected @endif>Painful</option>
                        <option value="painless" @if ((!empty($SkinDisease) && $SkinDisease['Rashes'] == 'painless') || old('rashes') == 'painless') selected @endif>painless</option>
                    </select>

                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="onset_of_rashes">Onset of rashes</label>
                    <input type="text" class="form-control" id="onset_of_rashes" name="onset_of_rashes"
                        @if (!empty($SkinDisease['OnsetOfRashes'])) value="{{ $SkinDisease['OnsetOfRashes'] }}"
                            @else
                            value="{{ old('onset_of_rashes') }}" @endif
                        required>
                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="rashes_site">Site</label>
                    <input type="text" class="form-control" id="rashes_site" name="rashes_site"
                        @if (!empty($SkinDisease['Site'])) value="{{ $SkinDisease['Site'] }}"
                            @else
                            value="{{ old('rashes_site') }}" @endif
                        required>



                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="started_from">Started From</label>
                    <input type="text" class="form-control" id="started_from" name="started_from"
                        @if (!empty($SkinDisease['StartedFrom'])) value="{{ $SkinDisease['StartedFrom'] }}"
                            @else
                            value="{{ old('started_from') }}" @endif
                        required>
                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="itching">Itching</label>
                    <input type="text" class="form-control" id="itching" name="itching"
                        @if (!empty($SkinDisease['Itching'])) value="{{ $SkinDisease['Itching'] }}"
                            @else
                            value="{{ old('itching') }}" @endif
                        required>
                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="rashes_fever">Fever</label>
                    <select class="form-control" id="rashes_fever" name="rashes_fever" required>
                        <option value="" @if (empty($SkinDisease['Fever']) && !old('rashes_fever')) selected @endif>Select</option>
                        <option value="onset" @if ((!empty($SkinDisease) && $SkinDisease['Fever'] == 'onset') || old('rashes_fever') == 'onset') selected @endif>onset</option>
                        <option value="before rash" @if ((!empty($SkinDisease) && $SkinDisease['Fever'] == 'before rash') || old('rashes_fever') == 'before rash') selected @endif>before rash
                        </option>
                        <option value="after rash" @if ((!empty($SkinDisease) && $SkinDisease['Fever'] == 'after rash') || old('rashes_fever') == 'after rash') selected @endif>after rash
                        </option>
                    </select>

                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="coryza">Coryza</label>
                    <input type="text" class="form-control" id="coryza" name="coryza"
                        @if (!empty($SkinDisease['Coryza'])) value="{{ $SkinDisease['Coryza'] }}"
                            @else
                            value="{{ old('coryza') }}" @endif
                        required>
                </div>
            </div>
        </div>

        <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
        <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
    </div>


    <div class="step " id="step14">
        <h3>Chief Complaint</h3>
        <div class="form-row">
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="chief_complaint">Chief Complaint</label>
                    <select class="form-control" id="chief_complaint" name="chief_complaint" required>
                        <option value="" @if (empty($ChiefComplaint['chief_complaint']) && !old('chief_complaint')) selected @endif>Select</option>
                        <option value="Fungal Infection" @if (
                            (!empty($ChiefComplaint) && $ChiefComplaint['chief_complaint'] == 'Fungal Infection') ||
                                old('chief_complaint') == 'Fungal Infection') selected @endif>Fungal
                            Infection</option>
                        <option value="Dermatitis" @if (
                            (!empty($ChiefComplaint) && $ChiefComplaint['chief_complaint'] == 'Dermatitis') ||
                                old('chief_complaint') == 'Dermatitis') selected @endif>Dermatitis
                        </option>
                        <option value="Scabies" @if ((!empty($ChiefComplaint) && $ChiefComplaint['chief_complaint'] == 'Scabies') || old('chief_complaint') == 'Scabies') selected @endif>Scabies</option>
                        <option value="Herpes" @if ((!empty($ChiefComplaint) && $ChiefComplaint['chief_complaint'] == 'Herpes') || old('chief_complaint') == 'Herpes') selected @endif>Herpes</option>
                        <option value="Other" @if ((!empty($ChiefComplaint) && $ChiefComplaint['chief_complaint'] == 'Other') || old('chief_complaint') == 'Other') selected @endif>Other</option>
                    </select>

                </div>
            </div>

            <div class="form-group col-md-6" id="chef_comlaint_div"
                @if (!empty($ChiefComplaint['chef_comlaint_specify'])) @else
           
            style="display:none"> @endif <div
                class="form-group">
                <label for="chef_comlaint_specify">Specify</label>
                <input type="text" class="form-control" id="chef_comlaint_specify" name="chef_comlaint_specify"
                    @if (!empty($ChiefComplaint['chef_comlaint_specify'])) value="{{ $ChiefComplaint['chef_comlaint_specify'] }}"
                        @else
                        value="{{ old('chef_comlaint_specify') }}" @endif>
            </div>
        </div>
        <h6 class="w-100">
            Past Medical History
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="previous_skin_conditions">Previous skin conditions or diseases</label>
                <input type="text" class="form-control" id="previous_skin_conditions"
                    name="previous_skin_conditions"
                    @if (!empty($ChiefComplaint['previous_skin_conditions'])) value="{{ $ChiefComplaint['previous_skin_conditions'] }}"
                        @else
                        value="{{ old('previous_skin_conditions') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="skincare_products">Allergies or sensitivities to medications or skincare
                    products</label>
                <input type="text" class="form-control" id="skincare_products" name="skincare_products"
                    @if (!empty($ChiefComplaint['skincare_products'])) value="{{ $ChiefComplaint['skincare_products'] }}"
                    @else
                    value="{{ old('skincare_products') }}" @endif
                    required>
            </div>
        </div>

        <h6 class="w-100">
            Family History
        </h6>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="family_skin_disease">Family history of skin diseases (specify if known)</label>
                <input type="text" class="form-control" id="family_skin_disease" name="family_skin_disease"
                    @if (!empty($ChiefComplaint['family_skin_disease'])) value="{{ $ChiefComplaint['family_skin_disease'] }}"
                    @else
                    value="{{ old('family_skin_disease') }}" @endif
                    required>
            </div>
        </div>

        <h6 class="w-100">
            Fungal Infections:ring like lesion ,white lesion ,itching then suspect fungal infections
        </h6>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="fungal_infections_type">Type</label>
                <input type="text" class="form-control" id="fungal_infections_type" name="fungal_infections_type"
                    @if (!empty($ChiefComplaint['fungal_infections_type'])) value="{{ $ChiefComplaint['fungal_infections_type'] }}"
                        @else
                        value="{{ old('fungal_infections_type') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="fungal_infections_duration">Duration (days/weeks/months/years)</label>
                <input type="text" class="form-control" id="fungal_infections_duration"
                    name="fungal_infections_duration"
                    @if (!empty($ChiefComplaint['fungal_infections_duration'])) value="{{ $ChiefComplaint['fungal_infections_duration'] }}"
                        @else
                        value="{{ old('fungal_infections_duration') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="fungal_previous_treatments">Previous treatments and efficacy</label>
                <input type="text" class="form-control" id="fungal_previous_treatments"
                    name="fungal_previous_treatments"
                    @if (!empty($ChiefComplaint['fungal_previous_treatments'])) value="{{ $ChiefComplaint['fungal_previous_treatments'] }}"
                        @else
                        value="{{ old('fungal_previous_treatments') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="fungal_infections_recurrence">Recurrence or spread</label>
                <select class="form-control" id="fungal_infections_recurrence" name="fungal_infections_recurrence"
                    required>
                    <option value="" @if (empty($ChiefComplaint['fungal_infections_recurrence']) && !old('fungal_infections_recurrence')) selected @endif>Select</option>
                    <option value="Yes" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['fungal_infections_recurrence'] == 'Yes') ||
                            old('fungal_infections_recurrence') == 'Yes') selected @endif>Yes</option>
                    <option value="No" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['fungal_infections_recurrence'] == 'No') ||
                            old('fungal_infections_recurrence') == 'No') selected @endif>No</option>
                </select>

            </div>
        </div>
        <h6 class="w-100">
            Dermatitis
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="dermatitis_type">Type: _irritant or contact or atopic</label>
                <input type="text" class="form-control" id="dermatitis_type" name="dermatitis_type"
                    @if (!empty($ChiefComplaint['dermatitis_type'])) value="{{ $ChiefComplaint['dermatitis_type'] }}"
                    @else
                    value="{{ old('dermatitis_type') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="dermatitis_triggers">Triggers or aggravating factors</label>
                <input type="text" class="form-control" id="dermatitis_triggers" name="dermatitis_triggers"
                    @if (!empty($ChiefComplaint['dermatitis_triggers'])) value="{{ $ChiefComplaint['dermatitis_triggers'] }}"
                    @else
                    value="{{ old('dermatitis_triggers') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="dermatitis_symptoms">Symptoms</label>
                <input type="text" class="form-control" id="dermatitis_symptoms" name="dermatitis_symptoms"
                    @if (!empty($ChiefComplaint['dermatitis_symptoms'])) value="{{ $ChiefComplaint['dermatitis_symptoms'] }}"
                    @else
                    value="{{ old('dermatitis_symptoms') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="dermatitis_previous_treatments">Previous treatments and response</label>
                <input type="text" class="form-control" id="dermatitis_previous_treatments"
                    name="dermatitis_previous_treatments"
                    @if (!empty($ChiefComplaint['dermatitis_previous_treatments'])) value="{{ $ChiefComplaint['dermatitis_previous_treatments'] }}"
                        @else
                        value="{{ old('dermatitis_previous_treatments') }}" @endif
                    required>
            </div>
        </div>
        <h6 class="w-100">
            Scabies:if severe itching with linear burrows
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="scabies_history">History of exposure</label>

                <select class="form-control" id="scabies_history" name="scabies_history" required>
                    <option value="" @if (empty($ChiefComplaint['scabies_history']) && !old('scabies_history')) selected @endif>Select</option>
                    <option value="Yes" @if ((!empty($ChiefComplaint) && $ChiefComplaint['scabies_history'] == 'Yes') || old('scabies_history') == 'Yes') selected @endif>Yes</option>
                    <option value="No" @if ((!empty($ChiefComplaint) && $ChiefComplaint['scabies_history'] == 'No') || old('scabies_history') == 'No') selected @endif>No</option>
                </select>


            </div>
        </div>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="scabies_symptoms">Symptoms</label>
                <input type="text" class="form-control" id="scabies_symptoms" name="scabies_symptoms"
                    @if (!empty($ChiefComplaint['scabies_symptoms'])) value="{{ $ChiefComplaint['scabies_symptoms'] }}"
                    @else
                    value="{{ old('scabies_symptoms') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="scabies_previous_treatments">Previous treatments and response</label>
                <input type="text" class="form-control" id="scabies_previous_treatments"
                    name="scabies_previous_treatments"
                    @if (!empty($ChiefComplaint['scabies_previous_treatments'])) value="{{ $ChiefComplaint['scabies_previous_treatments'] }}"
                        @else
                        value="{{ old('scabies_previous_treatments') }}" @endif
                    required>
            </div>
        </div>
        <h6 class="w-100">
            Herpes: if painful lesion especially around corner of mouth
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_type">Type: (oral/genital)</label>
                <input type="text" class="form-control" id="herpes_type" name="herpes_type"
                    @if (!empty($ChiefComplaint['herpes_type'])) value="{{ $ChiefComplaint['herpes_type'] }}"
                    @else
                    value="{{ old('herpes_type') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_triggers">Triggers for outbreaks</label>
                <input type="text" class="form-control" id="herpes_triggers" name="herpes_triggers"
                    @if (!empty($ChiefComplaint['herpes_triggers'])) value="{{ $ChiefComplaint['herpes_triggers'] }}"
                    @else
                    value="{{ old('herpes_triggers') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_location">Location</label>
                <input type="text" class="form-control" id="herpes_location" name="herpes_location"
                    @if (!empty($ChiefComplaint['herpes_location'])) value="{{ $ChiefComplaint['herpes_location'] }}"
                    @else
                    value="{{ old('herpes_location') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_pain">pain</label>
                <input type="text" class="form-control" id="herpes_pain" name="herpes_pain"
                    @if (!empty($ChiefComplaint['herpes_pain'])) value="{{ $ChiefComplaint['herpes_pain'] }}"
                    @else
                    value="{{ old('herpes_pain') }}" @endif
                    required>




            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_symptoms">Symptoms during outbreaks</label>
                <input type="text" class="form-control" id="herpes_symptoms" name="herpes_symptoms"
                    @if (!empty($ChiefComplaint['herpes_symptoms'])) value="{{ $ChiefComplaint['herpes_symptoms'] }}"
                    @else
                    value="{{ old('herpes_symptoms') }}" @endif
                    required>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_previous_treatments">Previous antiviral treatments and
                    effectiveness</label>
                <input type="text" class="form-control" id="herpes_previous_treatments"
                    name="herpes_previous_treatments"
                    @if (!empty($ChiefComplaint['herpes_previous_treatments'])) value="{{ $ChiefComplaint['herpes_previous_treatments'] }}"
                    @else
                    value="{{ old('herpes_previous_treatments') }}" @endif
                    required>
            </div>
        </div>
        <h6 class="w-100">
            Current Medications
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="herpes_current_medication">Any current medications, including topical treatments
                    for skin conditions.</label>
                <input type="text" class="form-control" id="herpes_current_medication"
                    name="herpes_current_medication"
                    @if (!empty($ChiefComplaint['herpes_current_medication'])) value="{{ $ChiefComplaint['herpes_current_medication'] }}"
                        @else
                        value="{{ old('herpes_current_medication') }}" @endif
                    required>
            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="current_additional_notes">Additional Notes</label>
                <input type="text" class="form-control" id="current_additional_notes"
                    name="current_additional_notes"
                    @if (!empty($ChiefComplaint['current_additional_notes'])) value="{{ $ChiefComplaint['current_additional_notes'] }}"
                        @else
                        value="{{ old('current_additional_notes') }}" @endif
                    required>
            </div>
        </div>

        <h6 class="w-100">
            Menstural History
        </h6>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="age_first_menstrual">Age of first menstrual period (menarche)</label>

                <select class="form-control" id="age_first_menstrual" name="age_first_menstrual" required>
                    <option value="" @if (empty($ChiefComplaint['age_first_menstrual']) && !old('age_first_menstrual')) selected @endif>Select</option>
                    <option value="<10 years old" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['age_first_menstrual'] == '<10 years old') ||
                            old('age_first_menstrual') == '<10 years old') selected @endif>&lt;10 years old
                    </option>
                    <option value="10-12 years old" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['age_first_menstrual'] == '10-12 years old') ||
                            old('age_first_menstrual') == '10-12 years old') selected @endif>10-12 years old
                    </option>
                    <option value="13-15 years old" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['age_first_menstrual'] == '13-15 years old') ||
                            old('age_first_menstrual') == '13-15 years old') selected @endif>13-15 years old
                    </option>
                    <option value=">15 years old" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['age_first_menstrual'] == '>15 years old') ||
                            old('age_first_menstrual') == '>15 years old')
                        selected
                        @endif>&gt;15 years old</option>
                    <option value="Not started" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['age_first_menstrual'] == 'Not started') ||
                            old('age_first_menstrual') == 'Not started') selected @endif>Not started</option>
                </select>


            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="regularity_menstrual">Regularity of menstrual cycles</label>


                <select class="form-control" id="regularity_menstrual" name="regularity_menstrual" required>
                    <option value="" @if (empty($ChiefComplaint['regularity_menstrual']) && !old('regularity_menstrual')) selected @endif>Select</option>
                    <option value="Regular (occurring every 21-35 days)"
                        @if (
                            (!empty($ChiefComplaint) && $ChiefComplaint['regularity_menstrual'] == 'Regular (occurring every 21-35 days)') ||
                                old('regularity_menstrual') == 'Regular (occurring every 21-35 days)') selected @endif>Regular (occurring every 21-35 days)</option>
                    <option value="Irregular (less predictable, varying cycle lengths)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['regularity_menstrual'] == 'Irregular (less predictable, varying cycle lengths)') ||
                                old('regularity_menstrual') == 'Irregular (less predictable, varying cycle lengths)') selected @endif>Irregular (less predictable, varying cycle
                        lengths)</option>
                    <option value="Unsure" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['regularity_menstrual'] == 'Unsure') ||
                            old('regularity_menstrual') == 'Unsure') selected @endif>Unsure</option>
                </select>


            </div>
        </div>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="duration_menstrual">Duration of menstrual flow</label>


                <select class="form-control" id="duration_menstrual" name="duration_menstrual" required>
                    <option value="" @if (empty($ChiefComplaint['duration_menstrual']) && !old('duration_menstrual')) selected @endif>Select</option>
                    <option value="1-3 days" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['duration_menstrual'] == '1-3 days') ||
                            old('duration_menstrual') == '1-3 days') selected @endif>1-3 days</option>
                    <option value="4-5 days" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['duration_menstrual'] == '4-5 days') ||
                            old('duration_menstrual') == '4-5 days') selected @endif>4-5 days</option>
                    <option value="6-7 days" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['duration_menstrual'] == '6-7 days') ||
                            old('duration_menstrual') == '6-7 days') selected @endif>6-7 days</option>
                    <option value="More than 7 days" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['duration_menstrual'] == 'More than 7 days') ||
                            old('duration_menstrual') == 'More than 7 days') selected @endif>More than 7
                        days</option>
                </select>



            </div>
        </div>

        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="amount_menstrual_bleeding">Amount of menstrual bleeding</label>


                <select class="form-control" id="amount_menstrual_bleeding" name="amount_menstrual_bleeding" required>
                    <option value="" @if (empty($ChiefComplaint['amount_menstrual_bleeding']) && !old('amount_menstrual_bleeding')) selected @endif>Select</option>
                    <option value="Light (requires only a few pads per day)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['amount_menstrual_bleeding'] == 'Light (requires only a few pads per day)') ||
                                old('amount_menstrual_bleeding') == 'Light (requires only a few pads per day)') selected @endif>Light (requires only a few pads per day)
                    </option>
                    <option value="Moderate (requires several pads per day)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['amount_menstrual_bleeding'] == 'Moderate (requires several pads per day)') ||
                                old('amount_menstrual_bleeding') == 'Moderate (requires several pads per day)') selected @endif>Moderate (requires several pads per day)
                    </option>
                    <option value="Heavy (requires frequent pad/tampon changes)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['amount_menstrual_bleeding'] == 'Heavy (requires frequent pad/tampon changes)') ||
                                old('amount_menstrual_bleeding') == 'Heavy (requires frequent pad/tampon changes)') selected @endif>Heavy (requires frequent pad/tampon changes)
                    </option>
                </select>



            </div>
        </div>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="symptoms_menstruation">Symptoms experienced during menstruation</label>



                <select class="form-control" id="symptoms_menstruation" name="symptoms_menstruation" required>
                    <option value="" @if (empty($ChiefComplaint['symptoms_menstruation']) && !old('symptoms_menstruation')) selected @endif>Select</option>
                    <option value="Cramps" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Cramps') ||
                            old('symptoms_menstruation') == 'Cramps') selected @endif>Cramps</option>
                    <option value="Back pain" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Back pain') ||
                            old('symptoms_menstruation') == 'Back pain') selected @endif>Back pain</option>
                    <option value="Headaches" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Headaches') ||
                            old('symptoms_menstruation') == 'Headaches') selected @endif>Headaches</option>
                    <option value="Bloating" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Bloating') ||
                            old('symptoms_menstruation') == 'Bloating') selected @endif>Bloating</option>
                    <option value="Mood swings" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Mood swings') ||
                            old('symptoms_menstruation') == 'Mood swings') selected @endif>Mood swings</option>
                    <option value="Nausea" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Nausea') ||
                            old('symptoms_menstruation') == 'Nausea') selected @endif>Nausea</option>
                    <option value="Fatigue" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['symptoms_menstruation'] == 'Fatigue') ||
                            old('symptoms_menstruation') == 'Fatigue') selected @endif>Fatigue</option>
                </select>



            </div>
        </div>
        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="use_menstrual_products">Use of menstrual hygiene products</label>



                <select class="form-control" id="use_menstrual_products" name="use_menstrual_products" required>
                    <option value="" @if (empty($ChiefComplaint['use_menstrual_products']) && !old('use_menstrual_products')) selected @endif>Select</option>
                    <option value="Pads" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['use_menstrual_products'] == 'Pads') ||
                            old('use_menstrual_products') == 'Pads') selected @endif>Pads</option>
                    <option value="Other" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['use_menstrual_products'] == 'Other') ||
                            old('use_menstrual_products') == 'Other') selected @endif>Other</option>
                </select>



            </div>
        </div>
        <div class="form-group col-md-6" id="use_menstrual_products_div"
            @if (!empty($ChiefComplaint['menstrual_products_specify'])) @else
                        
            style="display:none;" @endif>>



            <div class="form-group">
                <label for="menstrual_products_specify">Please specify</label>
                <input type="text" class="form-control" id="menstrual_products_specify"
                    name="menstrual_products_specify"
                    @if (!empty($ChiefComplaint['menstrual_products_specify'])) value="{{ $ChiefComplaint['menstrual_products_specify'] }}"
                        @else
                        value="{{ old('menstrual_products_specify') }}" @endif>


            </div>
        </div>


        <div class="form-group col-md-6">
            <div class="form-group">
                <label for="history_menstrual_disorder">Any history of menstrual disorders or
                    complications</label>

                <select class="form-control" id="history_menstrual_disorder" name="history_menstrual_disorder"
                    required>
                    <option value="" @if (empty($ChiefComplaint['history_menstrual_disorder']) && !old('history_menstrual_disorder')) selected @endif>Select</option>
                    <option value="Dysmenorrhea (painful periods)" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['history_menstrual_disorder'] == 'Dysmenorrhea (painful periods)') ||
                            old('history_menstrual_disorder') == 'Dysmenorrhea (painful periods)') selected @endif>
                        Dysmenorrhea (painful periods)</option>
                    <option value="Amenorrhea (absence of periods)" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['history_menstrual_disorder'] == 'Amenorrhea (absence of periods)') ||
                            old('history_menstrual_disorder') == 'Amenorrhea (absence of periods)') selected @endif>
                        Amenorrhea (absence of periods)</option>
                    <option value="Menorrhagia (excessive menstrual bleeding)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['history_menstrual_disorder'] == 'Menorrhagia (excessive menstrual bleeding)') ||
                                old('history_menstrual_disorder') == 'Menorrhagia (excessive menstrual bleeding)') selected @endif>Menorrhagia (excessive menstrual bleeding)
                    </option>
                    <option value="Oligomenorrhea (infrequent periods)"
                        @if (
                            (!empty($ChiefComplaint) &&
                                $ChiefComplaint['history_menstrual_disorder'] == 'Oligomenorrhea (infrequent periods)') ||
                                old('history_menstrual_disorder') == 'Oligomenorrhea (infrequent periods)') selected @endif>Oligomenorrhea (infrequent periods)</option>
                    <option value="Other" @if (
                        (!empty($ChiefComplaint) && $ChiefComplaint['history_menstrual_disorder'] == 'Other') ||
                            old('history_menstrual_disorder') == 'Other') selected @endif>Other</option>
                </select>



            </div>
        </div>
        <div class="form-group col-md-6" id="dysmenorrhea_div"
            @if (!empty($ChiefComplaint['dysmenorrhea_onset'])) @else
            style="display:none;" @endif>


            <div class="form-group">
                <label for="dysmenorrhea_onset">Dysmenorrhea (painful periods):onset</label>
                <input type="text" class="form-control" id="dysmenorrhea_onset" name="dysmenorrhea_onset"
                    @if (!empty($ChiefComplaint['dysmenorrhea_onset'])) value="{{ $ChiefComplaint['dysmenorrhea_onset'] }}"
                    @else
                    value="{{ old('dysmenorrhea_onset') }}" @endif>



            </div>
        </div>
        <div class="form-group col-md-6" id="amenorrhea_div"
            @if (!empty($ChiefComplaint['amenorrhea_duration'])) @else

            style="display:none;" @endif>

            >
            <div class="form-group">
                <label for="amenorrhea_duration">Amenorrhea (absence of periods):duration</label>
                <input type="text" class="form-control" id="amenorrhea_duration" name="amenorrhea_duration"
                    @if (!empty($ChiefComplaint['amenorrhea_duration'])) value="{{ $ChiefComplaint['amenorrhea_duration'] }}"
                    @else
                    value="{{ old('amenorrhea_duration') }}" @endif>



            </div>
        </div>
        <div class="form-group col-md-6" id="menorrhagia_duration_div"
            @if (!empty($ChiefComplaint['menorrhagia_duration'])) @else
            style="display:none;" @endif>
            <div class="form-group">
                <label for="menorrhagia_duration">Menorrhagia (excessive menstrual bleeding) duration</label>
                <input type="text" class="form-control" id="menorrhagia_duration" name="menorrhagia_duration"
                    @if (!empty($ChiefComplaint['menorrhagia_duration'])) value="{{ $ChiefComplaint['menorrhagia_duration'] }}"
                    @else
                    value="{{ old('menorrhagia_duration') }}" @endif>



            </div>
        </div>
        <div class="form-group col-md-6" id="menorrhagia_severity_div"
            @if (!empty($ChiefComplaint['menorrhagia_severity'])) @else
            style="display:none;" @endif>
            <div class="form-group">
                <label for="menorrhagia_severity">Menorrhagia (excessive menstrual bleeding) severity</label>
                <input type="text" class="form-control" id="menorrhagia_severity" name="menorrhagia_severity"
                    @if (!empty($ChiefComplaint['menorrhagia_severity'])) value="{{ $ChiefComplaint['menorrhagia_severity'] }}"
                        @else
                        value="{{ old('menorrhagia_severity') }}" @endif>



            </div>
        </div>
        <div class="form-group col-md-6" id="oligomenorrhea_duration_div"
            @if (!empty($ChiefComplaint['oligomenorrhea_duration'])) @else
            style="display:none;" @endif>
            <div class="form-group">
                <label for="oligomenorrhea_duration">Oligomenorrhea (infrequent periods):duration</label>
                <input type="text" class="form-control" id="oligomenorrhea_duration"
                    name="oligomenorrhea_duration"
                    @if (!empty($ChiefComplaint['oligomenorrhea_duration'])) value="{{ $ChiefComplaint['oligomenorrhea_duration'] }}"
                        @else
                        value="{{ old('oligomenorrhea_duration') }}" @endif>



            </div>
        </div>
        <div class="form-group col-md-6" id="menstrual_disorder_other_div"
            @if (!empty($ChiefComplaint['menstrual_disorder_other'])) @else
            style="display:none;" @endif>
            <div class="form-group">
                <label for="menstrual_disorder_other">Please specify</label>
                <input type="text" class="form-control" id="menstrual_disorder_other"
                    name="menstrual_disorder_other"
                    @if (!empty($ChiefComplaint['menstrual_disorder_other'])) value="{{ $ChiefComplaint['menstrual_disorder_other'] }}"
                        @else
                        value="{{ old('menstrual_disorder_other') }}" @endif>




            </div>
        </div>
    </div>

    <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
    <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
    </div>


    <div class="step " id="step15">

        <div class="form-row">
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="any_previous_medication_menstruation">Any previous medical treatments or
                        interventions related to menstruation</label>


                    <select class="form-control" id="any_previous_medication_menstruation"
                        name="any_previous_medication_menstruation" required>
                        <option value="" @if (empty($previousMenstruationTreatmentOrInterventions['PreviousMenstruationTreatmentOrInterventions']) &&
                                !old('any_previous_medication_menstruation')) selected @endif>Select</option>
                        <option value="Pain medications" @if (
                            (!empty($previousMenstruationTreatmentOrInterventions) &&
                                $previousMenstruationTreatmentOrInterventions['PreviousMenstruationTreatmentOrInterventions'] ==
                                    'Pain medications') ||
                                old('any_previous_medication_menstruation') == 'Pain medications') selected @endif>Pain
                            medications</option>
                        <option value="Other" @if (
                            (!empty($previousMenstruationTreatmentOrInterventions) &&
                                $previousMenstruationTreatmentOrInterventions['PreviousMenstruationTreatmentOrInterventions'] == 'Other') ||
                                old('any_previous_medication_menstruation') == 'Other') selected @endif>Other</option>
                    </select>


                </div>
            </div>

            <div class="form-group col-md-6" id="medication_menstruation_other_div"
                @if (!empty($previousMenstruationTreatmentOrInterventions['Specify'])) @else
                        
                        style="display:none" @endif>
                <div class="form-group">
                    <label for="medication_menstruation_other">Please specify</label>
                    <input type="text" class="form-control" id="medication_menstruation_other"
                        name="medication_menstruation_other"
                        @if (!empty($previousMenstruationTreatmentOrInterventions['Specify'])) value="{{ $previousMenstruationTreatmentOrInterventions['Specify'] }}"
                        @else
                        value="{{ old('medication_menstruation_other') }}" @endif>



                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="additional_concerns">Additional comments or concerns</label>
                    <input type="text" class="form-control" id="additional_concerns" name="additional_concerns"
                        @if (!empty($previousMenstruationTreatmentOrInterventions['comment'])) value="{{ $previousMenstruationTreatmentOrInterventions['comment'] }}"
                    @else
                    value="{{ old('additional_concerns') }}" @endif
                        required>
                </div>
            </div>
            <h6 class="w-100">
                Past Medical Conditions
            </h6>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="longterm_health">long-term health conditions</label>


                    <select class="form-control" id="longterm_health" name="longterm_health" required>
                        <option value="" @if (empty($PastMedicalConditions['LongTermHealthConditions']) && !old('longterm_health')) selected @endif>Select</option>
                        <option value="Asthma" @if (
                            (!empty($PastMedicalConditions) && $PastMedicalConditions['LongTermHealthConditions'] == 'Asthma') ||
                                old('longterm_health') == 'Asthma') selected @endif>Asthma</option>
                        <option value="Diabetes" @if (
                            (!empty($PastMedicalConditions) && $PastMedicalConditions['LongTermHealthConditions'] == 'Diabetes') ||
                                old('longterm_health') == 'Diabetes') selected @endif>Diabetes</option>
                        <option value="Hypertension" @if (
                            (!empty($PastMedicalConditions) && $PastMedicalConditions['LongTermHealthConditions'] == 'Hypertension') ||
                                old('longterm_health') == 'Hypertension') selected @endif>Hypertension
                        </option>
                        <option value="Other" @if (
                            (!empty($PastMedicalConditions) && $PastMedicalConditions['LongTermHealthConditions'] == 'Other') ||
                                old('longterm_health') == 'Other') selected @endif>Other</option>
                    </select>


                </div>
            </div>

            <div class="form-group col-md-6" id="longterm_health_other_div"
                @if (!empty($PastMedicalConditions['longterm_health_other'])) @else
            style="display:none" @endif>
                <div class="form-group">
                    <label for="longterm_health_other">Please specify</label>
                    <input type="text" class="form-control" id="longterm_health_other"
                        name="longterm_health_other"
                        @if (!empty($PastMedicalConditions['longterm_health_other'])) value="{{ $PastMedicalConditions['longterm_health_other'] }}"
                        @else
                        value="{{ old('longterm_health_other') }}" @endif>



                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="accident_or_injuries">Accident or Injuries</label>
                    <input type="text" class="form-control" id="accident_or_injuries" name="accident_or_injuries"
                        @if (!empty($PastMedicalConditions['AccidentOrInjuries'])) value="{{ $PastMedicalConditions['AccidentOrInjuries'] }}"
                    @else
                    value="{{ old('accident_or_injuries') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="surgeries">Surgeries</label>
                    <input type="text" class="form-control" id="surgeries" name="surgeries"
                        @if (!empty($PastMedicalConditions['Surgeries'])) value="{{ $PastMedicalConditions['Surgeries'] }}"
                    @else
                    value="{{ old('surgeries') }}" @endif
                        required>


                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="any_current_medications">Any Current medications</label>
                    <input type="text" class="form-control" id="any_current_medications"
                        name="any_current_medications"
                        @if (!empty($PastMedicalConditions['AnyCurrentMdications'])) value="{{ $PastMedicalConditions['AnyCurrentMdications'] }}"
                        @else
                        value="{{ old('any_current_medications') }}" @endif
                        required>



                </div>
            </div>
            <h6 class="w-100">
                Allergies
            </h6>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_medications">Medications</label>
                    <input type="text" class="form-control" id="alergies_medications" name="alergies_medications"
                        @if (!empty($Allergies['Medications'])) value="{{ $Allergies['Medications'] }}"
                    @else
                    value="{{ old('alergies_medications') }}" @endif
                        required>



                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_chemicals">Chemicals</label>
                    <input type="text" class="form-control" id="alergies_chemicals" name="alergies_chemicals"
                        @if (!empty($Allergies['Chemicals'])) value="{{ $Allergies['Chemicals'] }}"
                    @else
                    value="{{ old('alergies_chemicals') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_pollen">Pollen/Furs</label>
                    <input type="text" class="form-control" id="alergies_pollen" name="alergies_pollen"
                        @if (!empty($Allergies['PollenFurs'])) value="{{ $Allergies['PollenFurs'] }}"
                    @else
                    value="{{ old('alergies_pollen') }}" @endif
                        required>



                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_food">Food</label>
                    <input type="text" class="form-control" id="alergies_food" name="alergies_food"
                        @if (!empty($Allergies['Food'])) value="{{ $Allergies['Food'] }}"
                    @else
                    value="{{ old('alergies_food') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_metals">Metals</label>
                    <input type="text" class="form-control" id="alergies_metals" name="alergies_metals"
                        @if (!empty($Allergies['Metals'])) value="{{ $Allergies['Metals'] }}"
                    @else
                    value="{{ old('alergies_metals') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="alergies_other">Other</label>
                    <input type="text" class="form-control" id="alergies_other" name="alergies_other"
                        @if (!empty($Allergies['Other'])) value="{{ $Allergies['Other'] }}"
                    @else
                    value="{{ old('alergies_other') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="family_history_past">Family History</label>

                    <select class="form-control" id="family_history_past" name="family_history_past" required>
                        <option value="" @if (empty($Allergies['FamilyHistory']) && !old('family_history_past')) selected @endif>Select</option>
                        <option value="heart disease" @if (
                            (!empty($Allergies) && $Allergies['FamilyHistory'] == 'heart disease') ||
                                old('family_history_past') == 'heart disease') selected @endif>Heart Disease
                        </option>
                        <option value="Hypertension" @if (
                            (!empty($Allergies) && $Allergies['FamilyHistory'] == 'Hypertension') ||
                                old('family_history_past') == 'Hypertension') selected @endif>Hypertension
                        </option>
                        <option value="Obesity" @if ((!empty($Allergies) && $Allergies['FamilyHistory'] == 'Obesity') || old('family_history_past') == 'Obesity') selected @endif>Obesity</option>
                        <option value="Cancer" @if ((!empty($Allergies) && $Allergies['FamilyHistory'] == 'Cancer') || old('family_history_past') == 'Cancer') selected @endif>Cancer</option>
                        <option value="Diabetes" @if ((!empty($Allergies) && $Allergies['FamilyHistory'] == 'Diabetes') || old('family_history_past') == 'Diabetes') selected @endif>Diabetes</option>
                        <option value="or other" @if ((!empty($Allergies) && $Allergies['FamilyHistory'] == 'or other') || old('family_history_past') == 'or other') selected @endif>Other</option>
                    </select>


                </div>
            </div>
        </div>

        <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
        <button type="button" class="btn btn-primary nextStep mb-3">Next</button>
    </div>

    <div class="step" id="step16">


        <h3>SOCIOECONOMIC</h3>
        <div class="form-row">
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="water">Water</label>



                    <select class="form-control" id="water" name="water" required>
                        <option value="" @if (empty($Socioeconomic['Water']) && !old('water')) selected @endif>Select</option>
                        <option value="Tap" @if ((!empty($Socioeconomic) && $Socioeconomic['Water'] == 'Tap') || old('water') == 'Tap') selected @endif>Tap</option>
                        <option value="Boiled" @if ((!empty($Socioeconomic) && $Socioeconomic['Water'] == 'Boiled') || old('water') == 'Boiled') selected @endif>Boiled</option>
                        <option value="filtered" @if ((!empty($Socioeconomic) && $Socioeconomic['Water'] == 'filtered') || old('water') == 'filtered') selected @endif>Filtered</option>
                    </select>


                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="milk">Milk </label>



                    <select class="form-control" id="milk" name="milk" required>

                        <option value="" @if (empty($Socioeconomic['Milk']) && !old('milk')) selected @endif>Select</option>
                        <option value="Boiled (unpasturized milk)" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['Milk'] == 'Boiled (unpasturized milk)') ||
                                old('milk') == 'Boiled (unpasturized milk)') selected @endif>
                            Boiled (unpasturized milk)</option>
                        <option value="Tetrapack" @if ((!empty($Socioeconomic) && $Socioeconomic['Milk'] == 'Tetrapack') || old('milk') == 'Tetrapack') selected @endif>Tetrapack</option>
                    </select>







                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="rooms">Rooms</label>



                    <select class="form-control" id="rooms" name="rooms" required>
                        <option value="" @if (empty($Socioeconomic['Rooms']) && !old('rooms')) selected @endif>Select</option>
                        <option value="1" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '1') || old('rooms') == '1') selected @endif>1</option>
                        <option value="2" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '2') || old('rooms') == '2') selected @endif>2</option>
                        <option value="3" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '3') || old('rooms') == '3') selected @endif>3</option>
                        <option value="4" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '4') || old('rooms') == '4') selected @endif>4</option>
                        <option value="5" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '5') || old('rooms') == '5') selected @endif>5</option>
                        <option value="5+" @if ((!empty($Socioeconomic) && $Socioeconomic['Rooms'] == '5+') || old('rooms') == '5+') selected @endif>5+</option>
                    </select>



                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="infectious_disease">Infectious disease and any sick people at home</label>



                    <select class="form-control" id="infectious_disease" name="infectious_disease" required>
                        <option value="" @if (empty($Socioeconomic['infectious_disease']) && !old('infectious_disease')) selected @endif>Select</option>
                        <option value="Yes" @if ((!empty($Socioeconomic) && $Socioeconomic['infectious_disease'] == 'Yes') || old('infectious_disease') == 'Yes') selected @endif>Yes</option>
                        <option value="NO" @if ((!empty($Socioeconomic) && $Socioeconomic['infectious_disease'] == 'NO') || old('infectious_disease') == 'NO') selected @endif>NO</option>
                    </select>

                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="father_occupation">Father Occupation</label>




                    <select class="form-control" id="father_occupation" name="father_occupation" required>
                        <option value="" @if (empty($Socioeconomic['FatherOccupation']) && !old('father_occupation')) selected @endif>Select</option>
                        <option value="Office worker" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Office worker') ||
                                old('father_occupation') == 'Office worker') selected @endif>Office worker
                        </option>
                        <option value="Welder" @if ((!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Welder') || old('father_occupation') == 'Welder') selected @endif>Welder</option>
                        <option value="Clerick" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Clerick') ||
                                old('father_occupation') == 'Clerick') selected @endif>Clerick</option>
                        <option value="Shopkeeper" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Shopkeeper') ||
                                old('father_occupation') == 'Shopkeeper') selected @endif>Shopkeeper
                        </option>
                        <option value="Tailor" @if ((!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Tailor') || old('father_occupation') == 'Tailor') selected @endif>Tailor</option>
                        <option value="Teacher" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Teacher') ||
                                old('father_occupation') == 'Teacher') selected @endif>Teacher</option>
                        <option value="Factory worker" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Factory worker') ||
                                old('father_occupation') == 'Factory worker') selected @endif>Factory
                            worker</option>
                        <option value="Own work" @if (
                            (!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Own work') ||
                                old('father_occupation') == 'Own work') selected @endif>Own work</option>
                        <option value="Driver" @if ((!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Driver') || old('father_occupation') == 'Driver') selected @endif>Driver</option>
                        <option value="Other" @if ((!empty($Socioeconomic) && $Socioeconomic['FatherOccupation'] == 'Other') || old('father_occupation') == 'Other') selected @endif>Other</option>
                    </select>


                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="ddx">DDX</label>
                    <input type="text" class="form-control" id="ddx" name="ddx"
                        @if (!empty($Socioeconomic['DDX'])) value="{{ $Socioeconomic['DDX'] }}"
                    @else
                    value="{{ old('ddx') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="note_to_principal">Note to principal</label>
                    <input type="text" class="form-control" id="note_to_principal" name="note_to_principal"
                        @if (!empty($Socioeconomic['NoteToPrincipal'])) value="{{ $Socioeconomic['NoteToPrincipal'] }}"
                    @else
                    value="{{ old('note_to_principal') }}" @endif
                        required>
                </div>
            </div>
            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="note_to_parent">Note to parent</label>
                    <input type="text" class="form-control" id="note_to_parent" name="note_to_parent"
                        @if (!empty($Socioeconomic['NoteToParent'])) value="{{ $Socioeconomic['NoteToParent'] }}"
                    @else
                    value="{{ old('note_to_parent') }}" @endif
                        required>
                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">
                    <label for="attach_picture">Attach Picture</label>
                    <input type="file" class="form-control" id="attach_picture" name="attach_picture"
                        @if (!empty($Socioeconomic['Picture'])) @else required @endif>



                </div>
            </div>

            <div class="form-group col-md-6">
                <div class="form-group">

                    @if (!empty($Socioeconomic['Picture']))
                        <a href="{{ asset('uploads/patient') }}/{{ $Socioeconomic['Picture'] }}"
                            target="_blacnk">View</a>
                        <input type="hidden"
                            @if (!empty($Socioeconomic['Picture'])) value="{{ $Socioeconomic['Picture'] }}"
                @else
                value="{{ old('note_to_parent') }}" @endif
                            name="attach_picture_update">
                    @endif


                </div>
            </div>




            <button type="button" class="btn btn-primary prevStep mb-3">Previous</button>
            <button type="submit" class="btn btn-primary mb-3">Submit</button>
        </div>




    </div>

    </form>

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            console.log("HERE");
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            console.log("selectedValue " + selectedValue);

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            //     var nextStep = currentStep.next('.step');

            //     // Move to the next step
            //     currentStep.removeClass('active');
            //     nextStep.addClass('active');
            // });

            $('.prevStep').click(function() {
                var currentStep = $(this).closest('.step');
                var prevStep = currentStep.prev('.step');

                // Move to the previous step
                currentStep.removeClass('active');
                prevStep.addClass('active');
            });


            $(document).on("keyup blur", "#GrNo", function() {

                var GrNo = $(this).val();
                // console.log("GrNo " + GrNo);

                var base_url = '{!! Route('GetDetails') !!}';
                // console.log("base_url " + base_url);

                $.ajax({
                    url: base_url,
                    type: "post",
                    data: {
                        "_token": "{{ csrf_token() }}",
                        GrNo: GrNo
                    },

                    dataType: 'json',
                    beforeSend: function() {

                        console.log("----------- beforeSend -------------");
                    },

                    success: function(resp) {
                        // console.log("resp id " + resp.id);
                        // console.log("resp status " + resp['status']);
                        // console.log("resp " + resp);
                        // console.log("resp length " + resp.length);
                        console.log("resp " + JSON.stringify(resp));

                        if (resp['status'] === true) {


                            $("#name").val(resp['Data']['name']);
                            $("#dob").val(resp['Data']['dob']);
                            $("#gender").val(resp['Data']['gender']);
                            $("#BloodGroup").val(resp['Data']['blood_group']);
                            $("#contact").val(resp['Data']['phone']);


                        } else {

                            $("#name").val('');
                            $("#dob").val('');
                            $("#gender").val('');
                            $("#BloodGroup").val('');
                            $("#contact").val('');

                        }



                    }
                });

            });
        });
    </script>
    </div>
@endsection