@php
    use App\Models\School;
    
@endphp
@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>
    {{-- <link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/sweetalert2@10"> --}}
    <script src="https://cdn.jsdelivr.net/npm/sweetalert2@10"></script>

    <link href="https://cdn.jsdelivr.net/npm/select2@4.1.0-rc.0/dist/css/select2.min.css" rel="stylesheet"/>
    <script src="https://cdn.jsdelivr.net/npm/select2@4.1.0-rc.0/dist/js/select2.min.js"></script>

    <script src="https://cdn.jsdelivr.net/jquery.validation/1.19.2/jquery.validate.min.js"></script>

    <meta name="csrf-token" content="{{ csrf_token() }}">

    <!-- Include Tagify CSS -->
    <link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/tagify/4.9.2/tagify.min.css">
    <!-- Include Tagify JS -->
    <script src="https://cdnjs.cloudflare.com/ajax/libs/tagify/4.9.2/tagify.min.js"></script>

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

        .step {
            display: none;
        }

        .step.active {
            display: block;
        }

        h1 {
            text-align: center;
        }
        .pdfLogo {
            display: none;
            width: 150px;
            margin-bottom: 25px;
        }
        #pdfLogo { 
            display: none;
            width: 150px;
            margin-bottom: 25px;
        }
        .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;
        }

        .nav-tabs .nav-link.active {
            background-color: #1c3866 !important;
            color: #fff !important;
            border-color: transparent transparent #f5f7fa;
        }

        .nav-tabs li a {
            padding: 8px 26px !important;
        }

        .nav-tabs .nav-link {
            border: 1px solid #dfdfdf;
            background-color: #ededed;
        }

        /* #multiStepForm input[readonly], #multiStepForm select[readonly] {
                                        background-color: #fff !important;
                                        color: #000 !important;
                                        border: 1px solid #ccc !important;
                                        pointer-events: none !important;
                                        touch-action: none !important;
                                    } */

        .form-control[readonly] {
            background-color: transparent;
            border: none;
            padding-left: 0;
        }

        select {
            appearance: none;
            /* Remove default arrow in Firefox */
            -webkit-appearance: none;
            /* Remove default arrow in older versions of Chrome/Safari */
            -moz-appearance: none;
            /* Remove default arrow in newer versions of Firefox */
        }

        #content #multiStepForm input[readonly],
        #content .form-control {
            background: transparent !important;
            border: none !important;
            box-shadow: none !important;
        }

        .tab-pane {
            page-break-before: always;
            /* Ensures each .section starts on a new page */
        }

        /* Optional: Adjust margins or other styles for better page layout */
        @page {
            size: A4;
            /* Set the page size */
            margin: 1cm;
            /* Adjust margins as needed */
        }

        .select2-container--default.select2-container--disabled .select2-selection--multiple {
            background: transparent;
            border: none !important;
        }

        .select2-container--default .select2-selection--multiple .select2-selection__clear {
            display: none;
        }

        .select2-container--default.select2-container--focus .select2-selection--multiple {
            border: 0 !important;
        }

        .select2-container--default .select2-selection--multiple .select2-selection__choice {
            background: none;
            border: none;
            padding-left: 0px;
        }
        .bg_drop {
            position: fixed;
            inset: 0;
            background: #fff5;
            display: none;
            height: 100vh;
            backdrop-filter: blur(5px);
            align-items: center;
            justify-content: center;
        }

        .bg_drop.active{
            display: flex;
        }
        .modal-backdrop {
            z-index: -1 !important;
        }

        .modal{
            height: 100vh
        }

        .modal-dialog {
            display: flex;
            flex-direction: row;
            align-items: center;
            justify-content: center;
            height: 100vh;
        }

        [dir] .modal-content .form-control {
            height: auto !important;
            padding: 10px;
        }

        tags.tagify.form-control tag {
            font-size: 14px;
        }
    </style>

    <div class="container">
        <div class="d-flex align-items-center justify-content-end my-4">
            <button class="btn btn-primary mr-2" type="button" data-toggle="modal" data-target="#sendMailModal"
                    id="downloadPDF2">Send
                Mail
            </button>
            <button id="downloadPDF" class="btn btn-primary ">Download PDF</button>
           {{-- <button id="generatePDF" onclick="generatePDF()" class="btn btn-primary ">Generate PDF Sample</button> --}}
            
        </div>
        <h1 class="my-2">Medical History</h1>

        @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
        
        <div id="content" class="container">
           
            <form id="multiStepForm"
                  @if (!empty($StudentBiodata)) action="{{ route('StudentBiodata') }}/{{ $StudentBiodata['id'] }}"
                  @else action="{{ route('StudentBiodata') }}" @endif
                  method="POST">

                <!-- Step-one -->
                <input type="hidden" name="_token" value="{{ csrf_token() }}">
                <div class="step active mb-5" id="step1">
                    
                    <h3>Student Biodata</h3>
                    <div class="form-row">
                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="GRNo">GR Number</label>
                                <input placeholder="GR Number" type="number" step="any" class="form-control"
                                       id="GRNo" name="GRNo"
                                       @if (!empty($StudentBiodata['GRNo'])) value="{{ $StudentBiodata['GRNo'] }}"
                                       @else
                                       value="{{ old('GRNo') }}" @endif
                                       required>
                                <span class="error-message"></span>
                            </div>
                        </div>

                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="dob">Date Of Birth</label>
                                <input type="date" class="form-control" id="dob" name="dob"
                                       @if (!empty($StudentBiodata['dob'])) value="{{ $StudentBiodata['dob'] }}"
                                       @else
                                       value="{{ old('dob') }}" @endif>
                            </div>
                        </div>


                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="Name">Name</label>
                                <input placeholder="Name" type="text" class="form-control" id="name" name="name"
                                       @if (!empty($StudentBiodata['name'])) value="{{ $StudentBiodata['name'] }}"
                                       @else
                                       value="{{ old('name') }}" @endif
                                       required>
                            </div>
                        </div>


                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="class">Class</label>
                                <input placeholder="Class" type="number" class="form-control" id="class" name="class"
                                       @if (!empty($StudentBiodata['class'])) value="{{ $StudentBiodata['class'] }}"
                                       @else
                                       value="{{ old('class') }}" @endif
                                       required>
                                <span class="error-message"></span>
                            </div>
                        </div>


                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="B_Form_Number">B-Form Number</label>
                                <input placeholder="B Form Number" type="number" class="form-control" id="B_Form_Number"
                                       name="B_Form_Number"
                                       @if (!empty($StudentBiodata['B_Form_Number'])) value="{{ $StudentBiodata['B_Form_Number'] }}"
                                       @else
                                       value="{{ old('B_Form_Number') }}" @endif
                                       required>
                                <span class="error-message"></span>
                            </div>
                        </div>


                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="age">Age</label>
                                <input placeholder="Age" type="number" class="form-control" id="age" name="age"
                                       @if (!empty($StudentBiodata['age'])) value="{{ $StudentBiodata['age'] }}"
                                       @else
                                       value="{{ old('age') }}" @endif
                                       required>
                            </div>
                        </div>

                        <div class="form-group col-md-12">
                            <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"
                                        {{ !empty($StudentBiodata['gender']) && $StudentBiodata['gender'] == 'male' ? 'selected' : (old('gender') == 'male' ? 'selected' : '') }}>
                                        Male
                                    </option>
                                    <option value="female"
                                        {{ !empty($StudentBiodata['gender']) && $StudentBiodata['gender'] == 'female' ? 'selected' : (old('gender') == 'female' ? 'selected' : '') }}>
                                        Female
                                    </option>
                                    <option value="other"
                                        {{ !empty($StudentBiodata['gender']) && $StudentBiodata['gender'] == 'other' ? 'selected' : (old('gender') == 'other' ? 'selected' : '') }}>
                                        Other
                                    </option>
                                </select>


                            </div>
                        </div>

                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="School_Name">School Name</label>

                                @php
    $Schools = School::get();
                                    
                                @endphp

@if (!empty($Schools))
@foreach ($Schools as $item)
        @if (!empty($StudentBiodata['School_Name']) && $StudentBiodata['School_Name'] == $item->id) 

        
        
           
        <input placeholder="School Name" type="text" class="form-control" id="School_Name"
                                       name="School_Name"
                                     value="{{ $item->school_name }}">

                                @php
                                    $SchoolEmail =  $item->email;
                                @endphp
        @endif
@endforeach
@endif


                                {{-- <input placeholder="School Name" type="text" class="form-control" id="School_Name"
                                       name="School_Name"
                                       @if (!empty($StudentBiodata['School_Name'])) value="{{ $StudentBiodata['School_Name'] }}"
                                       @else
                                       value="{{ old('School_Name') }}" @endif
                                       required> --}}


                            </div>
                        </div>

                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="Emergency_Contact_Number"> Contact Number</label>
                                <input placeholder="Contact Number" type="number" class="form-control"
                                       id="Contact_Number" name="Contact_Number"
                                       @if (!empty($StudentBiodata['Contact_Number'])) value="{{ $StudentBiodata['Contact_Number'] }}"
                                       @else
                                       value="{{ old('Contact_Number') }}" @endif
                                       required>
                            </div>
                        </div>
                        {{-- Emergency contact field added --}}
                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="Emergency_Contact_Number">Emergency Contact Number</label>
                                <input placeholder="Emergency Contact Number" type="number" class="form-control"
                                       id="Emergency_Contact_Number" name="Emergency_Contact_Number"
                                       @if (!empty($StudentBiodata['Emergency_Contact_Number'])) value="{{ $StudentBiodata['Emergency_Contact_Number'] }}"
                                       @else
                                       value="{{ old('Emergency_Contact_Number') }}" @endif
                                       required>
                            </div>
                        </div>
                    </div>

                    <div class="row">
                        <div class="form-group col-md-12">
                            <div class="form-group">
                                <label for="type_of_encounter">Type Of Encounter</label>

                                <select class="form-control" id="type_of_encounter" name="type_of_encounter" required>
                                    <option value="">Select</option>
                                    <option value="Case identified through Screening"
                                        {{ !empty($StudentBiodata['type_of_encounter']) && $StudentBiodata['type_of_encounter'] == 'Case identified through Screening' ? 'selected' : (old('type_of_encounter') == 'Case identified through Screening' ? 'selected' : '') }}>
                                        Case identified through Screening
                                    </option>
                                    <option value="New Case"
                                        {{ !empty($StudentBiodata['type_of_encounter']) && $StudentBiodata['type_of_encounter'] == 'New Case' ? 'selected' : (old('type_of_encounter') == 'New Case' ? 'selected' : '') }}>
                                        New Case
                                    </option>
                                    <option value="Follow-up Case"
                                        {{ !empty($StudentBiodata['type_of_encounter']) && $StudentBiodata['type_of_encounter'] == 'Follow-up Case' ? 'selected' : (old('type_of_encounter') == 'Follow-up Case' ? 'selected' : '') }}>
                                        Follow-up Case
                                    </option>
                                </select>

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

                    {{-- <button type="submit" class="btn btn-primary ">Next</button> --}}


                </div>


            </form>


            <div class="row">
                <div class="form-group col-md-12 my-3">
                    <ul class="nav nav-tabs justify-content-center mx-auto" id="myTab" role="tablist"
                        style="display: none;">
                        <li class="nav-item">
                            <a class="nav-link @if (!empty($SchoolHealthPhysician)) active @endif" id="home-tab"
                               data-toggle="tab" href="#home" role="tab" aria-controls="home"
                               aria-selected="true">School Health Physician</a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link  @if (!empty($NutritionistHistoryEvaluationSection)) active @endif"
                               id="profile-tab"
                               data-toggle="tab" href="#profile" role="tab" aria-controls="profile"
                               aria-selected="false">Nutritionist</a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link @if (!empty($PsychologistHistoryAssessmentSection)) active @endif"
                               id="contact-tab"
                               data-toggle="tab" href="#contact" role="tab" aria-controls="contact"
                               aria-selected="false">Psychologist</a>
                        </li>
                    </ul>
                    <div class="tab-content mb-5" id="myTabContent">

                        {{-- School Health Physician Tab --}}


                        <div class="tab-pane fade  @if (!empty($SchoolHealthPhysician)) active  show @endif py-4"
                             id="home" role="tabpanel" aria-labelledby="home-tab">

                            <form id="multiStepForm"
                                  action="{{ route('SchoolHealthPhysician') }}/{{ $StudentBiodataId }}}" method="POST">

                                @csrf
                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h3 class="text-center my-2">School Health Physician</h3>
                                <h4 class="mt-3">Medical History</h4>

                                {{-- <input type="text" name="StudentBiodataId" value="{{$StudentBiodataId}}" readonly > --}}
                                <div class="row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Chief_Complaints1">Chief Complaints</label>
                                            <input placeholder="Chief Complaints" name="Chief_Complaints1" required
                                                   id="Chief_Complaints1" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Chief_Complaints1'])) value="{{ $SchoolHealthPhysician['Chief_Complaints1'] }}"
                                                   @else
                                                   value="{{ old('Chief_Complaints1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="History_of_Presenting_Complaints1">History of Presenting
                                                Complaints</label>
                                            <input placeholder="History of Presenting Complaints" required
                                                   name="History_of_Presenting_Complaints1"
                                                   id="History_of_Presenting_Complaints1" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['History_of_Presenting_Complaints1'])) value="{{ $SchoolHealthPhysician['History_of_Presenting_Complaints1'] }}"
                                                   @else
                                                   value="{{ old('History_of_Presenting_Complaints1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Review_of_Systems">Review of Systems</label>
                                            <input placeholder="Review of Systems" name="Review_of_Systems" required
                                                   id="Review_of_Systems" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Review_of_Systems'])) value="{{ $SchoolHealthPhysician['Review_of_Systems'] }}"
                                                   @else
                                                   value="{{ old('Review_of_Systems') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="General">General</label>
                                            <input placeholder="General" name="General" id="General" required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['General'])) value="{{ $SchoolHealthPhysician['General'] }}"
                                                   @else
                                                   value="{{ old('General') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Eyes">Eyes</label>
                                            <input placeholder="Eyes" name="Eyes" id="Eyes" class="form-control"
                                                   required
                                                   @if (!empty($SchoolHealthPhysician['Eyes'])) value="{{ $SchoolHealthPhysician['Eyes'] }}"
                                                   @else
                                                   value="{{ old('Eyes') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Ears_Nose_and_Throat">Ears, Nose and Throat</label>
                                            <input placeholder="Ears, Nose and Throat" name="Ears_Nose_and_Throat"
                                                   required id="Ears_Nose_and_Throat" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Ears_Nose_and_Throat'])) value="{{ $SchoolHealthPhysician['Ears_Nose_and_Throat'] }}"
                                                   @else
                                                   value="{{ old('Ears_Nose_and_Throat') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Teeth">Teeth</label>
                                            <input placeholder="Teeth" name="Teeth" id="Teeth"
                                                   class="form-control" required
                                                   @if (!empty($SchoolHealthPhysician['Teeth'])) value="{{ $SchoolHealthPhysician['Teeth'] }}"
                                                   @else
                                                   value="{{ old('Teeth') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Cardiorespiratory">Cardiorespiratory</label>
                                            <input placeholder="Cardiorespiratory" name="Cardiorespiratory" required
                                                   id="Cardiorespiratory" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Cardiorespiratory'])) value="{{ $SchoolHealthPhysician['Cardiorespiratory'] }}"
                                                   @else
                                                   value="{{ old('Cardiorespiratory') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Gastrointestinal">Gastrointestinal</label>
                                            <input placeholder="Gastrointestinal" name="Gastrointestinal" required
                                                   id="Gastrointestinal" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Gastrointestinal'])) value="{{ $SchoolHealthPhysician['Gastrointestinal'] }}"
                                                   @else
                                                   value="{{ old('Gastrointestinal') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Genitourinary">Genitourinary</label>
                                            <input placeholder="Genitourinary" name="Genitourinary" id="Genitourinary"
                                                   required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Genitourinary'])) value="{{ $SchoolHealthPhysician['Genitourinary'] }}"
                                                   @else
                                                   value="{{ old('Genitourinary') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Neuromuscular">Neuromuscular</label>
                                            <input placeholder="Neuromuscular" name="Neuromuscular" id="Neuromuscular"
                                                   required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Neuromuscular'])) value="{{ $SchoolHealthPhysician['Neuromuscular'] }}"
                                                   @else
                                                   value="{{ old('Neuromuscular') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Endocrine">Endocrine</label>
                                            <input placeholder="Endocrine" name="Endocrine" id="Endocrine" required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Endocrine'])) value="{{ $SchoolHealthPhysician['Endocrine'] }}"
                                                   @else
                                                   value="{{ old('Endocrine') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Hematologic">Hematologic</label>
                                            <input placeholder="Hematologic" name="Hematologic" id="Hematologic"
                                                   required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Hematologic'])) value="{{ $SchoolHealthPhysician['Hematologic'] }}"
                                                   @else
                                                   value="{{ old('Hematologic') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Rheumatologic">Rheumatologic</label>
                                            <input placeholder="Rheumatologic" name="Rheumatologic" id="Rheumatologic"
                                                   required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Rheumatologic'])) value="{{ $SchoolHealthPhysician['Rheumatologic'] }}"
                                                   @else
                                                   value="{{ old('Rheumatologic') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Skin">Skin</label>
                                            <input placeholder="Skin" name="Skin" id="Skin" required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Skin'])) value="{{ $SchoolHealthPhysician['Skin'] }}"
                                                   @else
                                                   value="{{ old('Skin') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Investigations_Laboratory_Test_Reports1">Investigations /
                                                Laboratory
                                                Test Reports</label>
                                            <input placeholder="Investigations / Laboratory Test Reports" required
                                                   name="Investigations_Laboratory_Test_Reports1"
                                                   id="Investigations_Laboratory_Test_Reports1" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Investigations_Laboratory_Test_Reports1'])) value="{{ $SchoolHealthPhysician['Investigations_Laboratory_Test_Reports1'] }}"
                                                   @else
                                                   value="{{ old('Investigations_Laboratory_Test_Reports1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Medication_History">Medication History</label>
                                            <input placeholder="Medication History" name="Medication_History" required
                                                   id="Medication_History" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Medication_History'])) value="{{ $SchoolHealthPhysician['Medication_History'] }}"
                                                   @else
                                                   value="{{ old('Medication_History') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Allergies">Allergies</label>
                                            <input placeholder="Allergies" name="Allergies" id="Allergies" required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Allergies'])) value="{{ $SchoolHealthPhysician['Allergies'] }}"
                                                   @else
                                                   value="{{ old('Allergies') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Past_Medical_History">Past Medical History</label>
                                            <input placeholder="Past Medical History" name="Past_Medical_History"
                                                   required
                                                   id="Past_Medical_History" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Past_Medical_History'])) value="{{ $SchoolHealthPhysician['Past_Medical_History'] }}"
                                                   @else
                                                   value="{{ old('Past_Medical_History') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Past_Surgical_History">Past Surgical History</label>
                                            <input placeholder="Past Surgical History" name="Past_Surgical_History"
                                                   required id="Past_Surgical_History" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Past_Surgical_History'])) value="{{ $SchoolHealthPhysician['Past_Surgical_History'] }}"
                                                   @else
                                                   value="{{ old('Past_Surgical_History') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Birth_History">Birth History</label>
                                            <input placeholder="Birth History" name="Birth_History" id="Birth_History"
                                                   required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Birth_History'])) value="{{ $SchoolHealthPhysician['Birth_History'] }}"
                                                   @else
                                                   value="{{ old('Birth_History') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Immunizatio_History">Immunization History</label>
                                            <input placeholder="Immunization History" name="Immunizatio_History"
                                                   required
                                                   id="Immunizatio_History" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Immunizatio_History'])) value="{{ $SchoolHealthPhysician['Immunizatio_History'] }}"
                                                   @else
                                                   value="{{ old('Immunizatio_History') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Growth_Development_Puberty_changes">Growth & Development /
                                                Puberty
                                                changes</label>
                                            <input placeholder="Growth & Development / Puberty changes" required
                                                   name="Growth_Development_Puberty_changes"
                                                   id="Growth_Development_Puberty_changes" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Growth_Development_Puberty_changes'])) value="{{ $SchoolHealthPhysician['Growth_Development_Puberty_changes'] }}"
                                                   @else
                                                   value="{{ old('Growth_Development_Puberty_changes') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Nutrition_History">Nutrition History</label>
                                            <input placeholder="Nutrition History" name="Nutrition_History" required
                                                   id="Nutrition_History" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Nutrition_History'])) value="{{ $SchoolHealthPhysician['Nutrition_History'] }}"
                                                   @else
                                                   value="{{ old('Nutrition_History') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Family_History1">Family History</label>
                                            <input placeholder="Family History" name="Family_History1"
                                                   id="Family_History1" required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Family_History1'])) value="{{ $SchoolHealthPhysician['Family_History1'] }}"
                                                   @else
                                                   value="{{ old('Family_History1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Personal_Social_History1">Personal & Social History</label>
                                            <input placeholder="Personal & Social History"
                                                   name="Personal_Social_History1"
                                                   required id="Personal_Social_History1" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Personal_Social_History1'])) value="{{ $SchoolHealthPhysician['Personal_Social_History1'] }}"
                                                   @else
                                                   value="{{ old('Personal_Social_History1') }}" @endif />
                                        </div>
                                    </div>
                                </div>
                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h4 class="text-center mt-3">PHYSICAL EXAMINATION</h4>
                                <p class="font-weight-bolder">Vital Signs and Measurements</p>


                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">

                                            <label for="Blood_pressure">Blood Pressure (Systolic) <span
                                                    id="BloodPressureSystolic"></span></label>

                                            <input placeholder="Blood pressure" name="Blood_pressure"
                                                   id="Blood_pressure"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Blood_pressure'])) value="{{ $SchoolHealthPhysician['Blood_pressure'] }}"
                                                   @else
                                                   value="{{ old('Blood_pressure') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="BloodPressureDiastolic">Blood Pressure (Diastolic) <span
                                                    id="BloodPressureDiastolicSpan"></span> </label>
                                            <input placeholder="Blood Pressure (Diastolic) "
                                                   name="BloodPressureDiastolic"
                                                   id="BloodPressureDiastolic" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['BloodPressureDiastolic'])) value="{{ $SchoolHealthPhysician['BloodPressureDiastolic'] }}"
                                                   @else
                                                   value="{{ old('BloodPressureDiastolic') }}" @endif
                                                   required/>
                                        </div>
                                    </div>


                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Temperature">Temperature
                                                <span id="temperature_check"></span>
                                            </label>
                                            <input placeholder="Temperature" name="Temperature" id="Temperature"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Temperature'])) value="{{ $SchoolHealthPhysician['Temperature'] }}"
                                                   @else
                                                   value="{{ old('Temperature') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Pulse_rate">Pulse rate
                                                <span id="pulse_rate_check"></span>
                                            </label>
                                            <input placeholder="Pulse rate" name="Pulse_rate" id="Pulse_rate"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Pulse_rate'])) value="{{ $SchoolHealthPhysician['Pulse_rate'] }}"
                                                   @else
                                                   value="{{ old('Pulse_rate') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Respiratory_Rate">Respiratory Rate
                                                <span id="check_respiratory_rate"></span>
                                            </label>
                                            <input placeholder="Respiratory Rate" name="Respiratory_Rate"
                                                   id="Respiratory_Rate" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Respiratory_Rate'])) value="{{ $SchoolHealthPhysician['Respiratory_Rate'] }}"
                                                   @else
                                                   value="{{ old('Respiratory_Rate') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Weight">Weight <span id="Weight1Response1"></span></label>
                                            <input placeholder="Weight" name="Weight" id="Weight" type="number"
                                                   step="any" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Weight'])) value="{{ $SchoolHealthPhysician['Weight'] }}"
                                                   @else
                                                   value="{{ old('Weight') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Height">Height <span id="height1Response1"></span> </label>
                                            <input placeholder="Height" name="Height" id="Height" type="number"
                                                   step="any" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Height'])) value="{{ $SchoolHealthPhysician['Height'] }}"
                                                   @else
                                                   value="{{ old('Height') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="BMI">BMI <span id="bmi_result_1">
                                                </span> </label>
                                            <input placeholder="BMI" name="BMI" id="BMI" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['BMI'])) value="{{ $SchoolHealthPhysician['BMI'] }}"
                                                   @else
                                                   value="{{ old('BMI') }}" @endif
                                                   required readonly/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="General_Appearance">General Appearance</label>
                                            <input placeholder="General Appearance" name="General_Appearance"
                                                   id="General_Appearance" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['General_Appearance'])) value="{{ $SchoolHealthPhysician['General_Appearance'] }}"
                                                   @else
                                                   value="{{ old('General_Appearance') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Skin">Skin</label>
                                            <input placeholder="Skin" name="Skin" id="Skin" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Skin'])) value="{{ $SchoolHealthPhysician['Skin'] }}"
                                                   @else
                                                   value="{{ old('Skin') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Lymph Nodes">Lymph Nodes</label>
                                            <input placeholder="Lymph Nodes" name="Lymph_Nodes" id="Lymph_Nodes"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Lymph_Nodes'])) value="{{ $SchoolHealthPhysician['Lymph_Nodes'] }}"
                                                   @else
                                                   value="{{ old('Lymph_Nodes') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Head">Head </label>
                                            <input placeholder="Head" name="Head" id="Head" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Head'])) value="{{ $SchoolHealthPhysician['Head'] }}"
                                                   @else
                                                   value="{{ old('Head') }}" @endif
                                                   required/>


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Eyes">Eyes</label>
                                            <input placeholder="Eyes" name="Eyes" id="Eyes" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Eyes'])) value="{{ $SchoolHealthPhysician['Eyes'] }}"
                                                   @else
                                                   value="{{ old('Eyes') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="ENT">ENT</label>
                                            <input placeholder="ENT" name="ENT" id="ENT" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['ENT'])) value="{{ $SchoolHealthPhysician['ENT'] }}"
                                                   @else
                                                   value="{{ old('ENT') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Chest">Chest</label>
                                            <input placeholder="Chest" name="Chest" id="Chest"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Chest'])) value="{{ $SchoolHealthPhysician['Chest'] }}"
                                                   @else
                                                   value="{{ old('Chest') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Heart">Heart</label>
                                            <input placeholder="Heart" name="Heart" id="Heart"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Heart'])) value="{{ $SchoolHealthPhysician['Heart'] }}"
                                                   @else
                                                   value="{{ old('Heart') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Abdomen">Abdomen</label>
                                            <input placeholder="Abdomen" name="Abdomen" id="Abdomen"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Abdomen'])) value="{{ $SchoolHealthPhysician['Abdomen'] }}"
                                                   @else
                                                   value="{{ old('Abdomen') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Extremities">Extremities</label>
                                            <input placeholder="Extremities" name="Extremities" id="Extremities"
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Extremities'])) value="{{ $SchoolHealthPhysician['Extremities'] }}"
                                                   @else
                                                   value="{{ old('Extremities') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Neurologic_Examination">Neurologic Examination</label>
                                            <input placeholder="Neurologic Examination" name="Neurologic_Examination"
                                                   id="Neurologic_Examination" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Neurologic_Examination'])) value="{{ $SchoolHealthPhysician['Neurologic_Examination'] }}"
                                                   @else
                                                   value="{{ old('Neurologic_Examination') }}" @endif
                                                   required/>
                                        </div>
                                    </div>
                                </div>

                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h4 class="text-center mt-3">Diagnosis, Impression and Plan</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Problem_List">Problem List</label>
                                            <input placeholder="Problem List" name="Problem_List" id="Problem_List"
                                                   required class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Problem_List'])) value="{{ $SchoolHealthPhysician['Problem_List'] }}"
                                                   @else
                                                   value="{{ old('Problem_List') }}" @endif />


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Impression">Impression</label>
                                            <input placeholder="Impression" name="Impression" id="Impression" required
                                                   class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Impression'])) value="{{ $SchoolHealthPhysician['Impression'] }}"
                                                   @else
                                                   value="{{ old('Impression') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Provisional_Diagnosis">Provisional Diagnosis </label>
                                            @php
                                                $provisionalArray = [];
                                                if (!empty($SchoolHealthPhysician['Provisional_Diagnosis'])) {
                                                    $provisionalArray = explode(
                                                        '|',
                                                        $SchoolHealthPhysician['Provisional_Diagnosis'] ?? '',
                                                    );

                                                    // echo "<PRE>";print_r($provisionalArray);exit;
                                                }
                                            @endphp

                                            <select id="Provisional_Diagnosis" name="Provisional_Diagnosis[]" required
                                                    class="form-control js-states select_multi py-3" multiple>


                                                @if (!empty($ICD10))
                                                    @foreach ($ICD10 as $ICD1)
                                                        @php

                                                            $ICD1_value = $ICD1['code'] . '-' . $ICD1['description'];

                                                        @endphp

                                                        <option value="{{ $ICD1_value }}"
                                                            {{ in_array($ICD1_value, $provisionalArray) ? 'selected' : '' }}>
                                                            {{ $ICD1_value }}</option>
                                                    @endforeach
                                                @else
                                                    <option value="H10.9 Unspecified conjunctivitis"
                                                        {{ in_array('H10.9 Unspecified conjunctivitis', $provisionalArray) ? 'selected' : '' }}>
                                                        H10.9 Unspecified conjunctivitis
                                                    </option>
                                                    <option value="H10.32 Unspecified acute conjunctivitis, left eye"
                                                        {{ in_array('H10.32 Unspecified acute conjunctivitis, left eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H10.32 Unspecified acute conjunctivitis, left eye
                                                    </option>
                                                    <option value="H52.11 Myopia, right eye"
                                                        {{ in_array('H52.11 Myopia, right eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.11 Myopia, right eye
                                                    </option>
                                                    <option value="H52.12 Myopia, left eye"
                                                        {{ in_array('H52.12 Myopia, left eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.12 Myopia, left eye
                                                    </option>
                                                    <option value="H52.13 Myopia, bilateral"
                                                        {{ in_array('H52.13 Myopia, bilateral', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.13 Myopia, bilateral
                                                    </option>
                                                @endif


                                            </select>


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Investigations_Recommended">Investigations Recommended</label>

                                            <select id="Investigations_Recommended" name="Investigations_Recommended"
                                                    class="form-control" required>
                                                    <option value="">Select</option>
                                                    
                                                    <option value="Labs" @if (
                                                    !empty($SchoolHealthPhysician['Investigations_Recommended']) &&
                                                        $SchoolHealthPhysician['Investigations_Recommended'] == 'Labs') selected @endif>
                                                    Labs
                                                </option>
                                                <option value="Radiology"
                                                        @if (
                                                            !empty($SchoolHealthPhysician['Investigations_Recommended']) &&
                                                                $SchoolHealthPhysician['Investigations_Recommended'] == 'Radiology') selected @endif>
                                                    Radiology
                                                </option>
                                            </select>


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="General_Advice">General Advice & Management Plan</label>
                                            <input placeholder="General Advice & Management Plan" name="General_Advice"
                                                   id="General_Advice" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['General_Advice'])) value="{{ $SchoolHealthPhysician['General_Advice'] }}"
                                                   @else
                                                   value="{{ old('General_Advice') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="First_Aid_Given">First Aid Given</label>

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


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Required">Follow-up Required</label>

                                            <select id="Follow_up_Required" class="form-control" onchange="followUp()"
                                                    name="Follow_up_Required" required>
                                                <option value=""
                                                        @if (empty($SchoolHealthPhysician['Follow_up_Required'])) selected @endif>
                                                    Select
                                                </option>
                                                <option value="Yes"
                                                        @if (!empty($SchoolHealthPhysician['Follow_up_Required']) && $SchoolHealthPhysician['Follow_up_Required'] == 'Yes') selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (!empty($SchoolHealthPhysician['Follow_up_Required']) && $SchoolHealthPhysician['Follow_up_Required'] == 'No') selected @endif>
                                                    No
                                                </option>
                                            </select>


                                        </div>
                                    </div>


                                </div>
                                <div class="form-row d-none" id="follow_up_show">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Reason_for_Follow_up">Reason for Follow-up</label>
                                            <input placeholder="Reason for Follow-up" name="Reason_for_Follow_up"
                                                   id="Reason_for_Follow_up" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Reason_for_Follow_up'])) value="{{ $SchoolHealthPhysician['Reason_for_Follow_up'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Follow_up') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Date">Follow-up Date</label>
                                            <input type="date" placeholder="Reason for Follow-up"
                                                   name="Follow_up_Date" id="Follow_up_Date" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Follow_up_Date'])) value="{{ $SchoolHealthPhysician['Follow_up_Date'] }}"
                                                   @else
                                                   value="{{ old('Follow_up_Date') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <h3>Refferals</h3>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="internal_referrals">Internal Referrals</label>

                                            @php
                                                $internal_referralsArr = [];
                                                if (!empty($SchoolHealthPhysician['internal_referrals'])) {
                                                    $internal_referralsArr = explode(
                                                        '|',
                                                        $SchoolHealthPhysician['internal_referrals'] ?? '',
                                                    );

                                                    // echo "<PRE>";print_r($internal_referralsArr);exit;
                                                }
                                            @endphp

                                            <select id="internal_referrals" name="internal_referrals[]"
                                                    class="form-control js-states select_multi py-3" multiple required>
                                                <option value="Nutritionist"
                                                        @if (in_array('Nutritionist', $internal_referralsArr)) selected @endif>
                                                    Nutritionist
                                                </option>
                                                <option value="Psychologist"
                                                        @if (in_array('Psychologist', $internal_referralsArr)) selected @endif>
                                                    Psychologist
                                                </option>
                                                <option value="Add team lead"
                                                        @if (in_array('Psychologist', $internal_referralsArr)) selected @endif>
                                                    Psychologist
                                                </option>
                                            </select>


                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="external_referrals">External Referrals</label>

                                            @php
                                                $external_referralsArr = [];
                                                if (!empty($SchoolHealthPhysician['external_referrals'])) {
                                                    $external_referralsArr = explode(
                                                        '|',
                                                        $SchoolHealthPhysician['external_referrals'] ?? '',
                                                    );
                                                }
                                            @endphp


                                            <select id="external_referrals" name="external_referrals[]"
                                                    class="form-control js-states select_multi py-3" multiple required
                                                    onchange="showReasonForReferral()">

                                                @if (!empty($ExternalReferralList))
                                                    @foreach ($ExternalReferralList as $ExternalReferralLis)
                                                        <option value="{{ $ExternalReferralLis['name'] }}"
                                                                @if (in_array($ExternalReferralLis['name'], $external_referralsArr)) selected @endif>
                                                            {{ $ExternalReferralLis['name'] }}</option>
                                                    @endforeach
                                                @else
                                                    <option value="Allery and Immunology"
                                                            @if (in_array('Allery and Immunology', $external_referralsArr)) selected @endif>
                                                        Allery and
                                                        Immunology
                                                    </option>
                                                    <option value="Cardiology"
                                                            @if (in_array('Cardiology', $external_referralsArr)) selected @endif>
                                                        Cardiology
                                                    </option>
                                                    <option value="Clinical Psychology"
                                                            @if (in_array('Clinical Psychology', $external_referralsArr)) selected @endif>
                                                        Clinical
                                                        Psychology
                                                    </option>
                                                    <option value="Dentistry"
                                                            @if (in_array('Dentistry', $external_referralsArr)) selected @endif>
                                                        Dentistry
                                                    </option>
                                                    <option value="Dermatology"
                                                            @if (in_array('Dermatology', $external_referralsArr)) selected @endif>
                                                        Dermatology
                                                    </option>
                                                @endif
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12 d-none" id="reasonForReferralSection">
                                        <div class="form-group">
                                            <label for="Reason_for_Referral">Reason for Referral</label>
                                            <input placeholder="Reason for Referral" name="Reason_for_Referral"
                                                   id="Reason_for_Referral" class="form-control"
                                                   @if (!empty($SchoolHealthPhysician['Reason_for_Referral'])) value="{{ $SchoolHealthPhysician['Reason_for_Referral'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Referral') }}" @endif
                                                   required/>
                                        </div>
                                    </div>

                                </div>

                                {{-- <a href="{{ Route('StudentBiodata') }}/{{ $StudentBiodataId }}">
                                <button type="button" class="btn btn-primary prevStep">Previous</button>
                            </a>

                            <button type="submit" name="submit" class="btn btn-primary">Submit</button> --}}


                            </form>

                        </div>


                        <div
                            class="tab-pane fade @if (!empty($NutritionistHistoryEvaluationSection)) active show @endif"
                            id="profile"
                            role="tabpanel" aria-labelledby="profile-tab">

                            <form id="multiStepForm1"
                                  action="{{ route('NutritionistHistoryEvaluationSection') }}/{{ $StudentBiodataId }}}"
                                  method="POST">

                                @csrf

                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h3 class="text-center mt-4">Nutritionist History & Evaluation Section</h3>
                                <div id="chartContainer" style="height: 370px; width: 100%;" class="my-4"></div>
                                <h4 class="mt-4">Anthropometric Measurements</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="height">Height (cm) <span id="height1Response"></label>
                                            <input placeholder="Height (cm)" name="height" required id="height1"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['height'])) value="{{ $NutritionistHistoryEvaluationSection['height'] }}"
                                                   @else
                                                   value="{{ old('height') }}" @endif />
                                        </div>
                                    </div>
                                    <div>
                                        <input type="hidden" name="hidden_age" id="hidden_age"
                                               @if (!empty($monthsDifference)) value="{{ $monthsDifference }}" @endif
                                               readonly>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Weight">Weight (kg) <span id="Weight1Response"> </span></label>
                                            <input placeholder="Weight (kg)" name="Weight" required id="Weight1"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Weight'])) value="{{ $NutritionistHistoryEvaluationSection['Weight'] }}"
                                                   @else
                                                   value="{{ old('Weight') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="BMI">BMI (auto-generated) <span id="bmi_result">
                                                </span> </label>
                                            <input placeholder="BMI (auto-generated)" name="BMI" required
                                                   id="BMI1" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['BMI'])) value="{{ $NutritionistHistoryEvaluationSection['BMI'] }}"
                                                   @else
                                                   value="{{ old('BMI') }}" @endif
                                                   readonly/>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="MUAC">MUAC</label>
                                            <input placeholder="MUAC" name="MUAC" required id="MUAC"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['MUAC'])) value="{{ $NutritionistHistoryEvaluationSection['MUAC'] }}"
                                                   @else
                                                   value="{{ old('MUAC') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Ideal_Body_Weight">Ideal Body Weight (IBW)</label>
                                            <input placeholder="Ideal Body Weight (IBW)" name="Ideal_Body_Weight"
                                                   required
                                                   id="Ideal_Body_Weight" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Ideal_Body_Weight'])) value="{{ $NutritionistHistoryEvaluationSection['Ideal_Body_Weight'] }}"
                                                   @else
                                                   value="{{ old('Ideal_Body_Weight') }}" @endif />
                                        </div>
                                    </div>


                                </div>

                                <h4 class="mt-4">Estimated Nutrition Requirements</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Physical_Activity_Level">Physical Activity Level</label>
                                            <input readonly value="Physical Activity Levels"
                                                   placeholder="Physical Activity Level" name="Physical_Activity_Level"
                                                   required id="Physical_Activity_Level" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Physical_Activity_Level'])) value="{{ $NutritionistHistoryEvaluationSection['Physical_Activity_Level'] }}"
                                                   @else
                                                   value="{{ old('Physical_Activity_Level') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Estimated_Energy_Requirement">Estimated Energy
                                                Requirement</label>
                                            <input readonly value="Estimated Energy Requirement"
                                                   placeholder="Estimated Energy Requirement"
                                                   name="Estimated_Energy_Requirement" required
                                                   id="Estimated_Energy_Requirement" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Estimated_Energy_Requirement'])) value="{{ $NutritionistHistoryEvaluationSection['Estimated_Energy_Requirement'] }}"
                                                   @else
                                                   value="{{ old('Estimated_Energy_Requirement') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Daily_Protein_Requirement">Daily Protein Requirement</label>
                                            <input readonly value="Daily Protein Requirement"
                                                   placeholder="Daily Protein Requirement"
                                                   name="Daily_Protein_Requirement"
                                                   required id="Daily_Protein_Requirement" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Daily_Protein_Requirement'])) value="{{ $NutritionistHistoryEvaluationSection['Daily_Protein_Requirement'] }}"
                                                   @else
                                                   value="{{ old('Daily_Protein_Requirement') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Daily_Carbohydrate_Requirement">Daily Carbohydrate
                                                Requirement</label>
                                            <input readonly value="Daily Carbohydrate Requirement"
                                                   placeholder="Daily_Carbohydrate_Requirement"
                                                   name="Daily_Carbohydrate_Requirement" required
                                                   id="Daily_Carbohydrate_Requirement" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Daily_Carbohydrate_Requirement'])) value="{{ $NutritionistHistoryEvaluationSection['Daily_Carbohydrate_Requirement'] }}"
                                                   @else
                                                   value="{{ old('Daily_Carbohydrate_Requirement') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Daily_Fat_Requirement">Daily Fat Requirement</label>
                                            <input readonly value="Daily Fat Requirement"
                                                   placeholder="Daily_Fat_Requirement" name="Daily_Fat_Requirement"
                                                   required
                                                   id="Daily_Fat_Requirement" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Daily_Fat_Requirement'])) value="{{ $NutritionistHistoryEvaluationSection['Daily_Fat_Requirement'] }}"
                                                   @else
                                                   value="{{ old('Daily_Fat_Requirement') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Daily_Fluid_Requirement">Daily Fluid Requirement</label>
                                            <input readonly value="Daily Fluid Requirement"
                                                   placeholder="Daily Fluid Requirement" name="Daily_Fluid_Requirement"
                                                   required id="Daily_Fluid_Requirement" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Daily_Fluid_Requirement'])) value="{{ $NutritionistHistoryEvaluationSection['Daily_Fluid_Requirement'] }}"
                                                   @else
                                                   value="{{ old('Daily_Fluid_Requirement') }}" @endif />
                                        </div>
                                    </div>
                                </div>
                                <div class="tab-pane">

                                    <h4 class="mt-4">Dietary Evaluation</h4>

                                    <div class="form-row">
                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Chief_Complaints2">Chief Complaints</label>
                                                <input value="Chief Complaints" placeholder="Chief Complaints"
                                                       name="Chief_Complaints2" required id="Chief_Complaints2"
                                                       class="form-control"
                                                       @if (!empty($NutritionistHistoryEvaluationSection['Chief_Complaints2'])) value="{{ $NutritionistHistoryEvaluationSection['Chief_Complaints2'] }}"
                                                       @else
                                                       value="{{ old('Chief_Complaints2') }}" @endif />
                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="History_of_Presenting_Complains">History of Presenting
                                                    Complains</label>
                                                <input value="History of Presenting Complains"
                                                       placeholder="History of Presenting Complains"
                                                       name="History_of_Presenting_Complains" required
                                                       id="History_of_Presenting_Complains" class="form-control"
                                                       @if (!empty($NutritionistHistoryEvaluationSection['History_of_Presenting_Complains'])) value="{{ $NutritionistHistoryEvaluationSection['History_of_Presenting_Complains'] }}"
                                                       @else
                                                       value="{{ old('History_of_Presenting_Complains') }}" @endif />
                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Past_Medical_History">Past Medical History</label>
                                                <input value="Past Medical History" placeholder="Past Medical History"
                                                       name="Past_Medical_History" required id="Past_Medical_History"
                                                       class="form-control"
                                                       @if (!empty($NutritionistHistoryEvaluationSection['Past_Medical_History'])) value="{{ $NutritionistHistoryEvaluationSection['Past_Medical_History'] }}"
                                                       @else
                                                       value="{{ old('Past_Medical_History') }}" @endif />
                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label
                                                    for="Medication_Supplements_Allergies_History">Medication/Supplements/Allergies
                                                    History</label>
                                                <input value="Medication/Supplements/Allergies History"
                                                       placeholder="Medication/Supplements/Allergies History"
                                                       name="Medication_Supplements_Allergies_History" required
                                                       id="Medication_Supplements_Allergies_History"
                                                       class="form-control"
                                                       @if (!empty($NutritionistHistoryEvaluationSection['Medication_Supplements_Allergies_History'])) value="{{ $NutritionistHistoryEvaluationSection['Medication_Supplements_Allergies_History'] }}"
                                                       @else
                                                       value="{{ old('Medication_Supplements_Allergies_History') }}" @endif />
                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Family_History2">Family History</label>
                                                <input value="Family History" placeholder="Family History"
                                                       name="Family_History2" required id="Family_History2"
                                                       class="form-control"
                                                       @if (!empty($NutritionistHistoryEvaluationSection['Family_History2'])) value="{{ $NutritionistHistoryEvaluationSection['Family_History2'] }}"
                                                       @else
                                                       value="{{ old('Family_History2') }}" @endif />
                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Personal_Social_History2">Personal & Social History</label>
                                                <input placeholder="Personal & Social History"
                                                       name="Personal_Social_History2" required
                                                       id="Personal_Social_History2"
                                                       class="form-control"
                                                       value="{{ !empty($NutritionistHistoryEvaluationSection['Personal_Social_History2']) ? $NutritionistHistoryEvaluationSection['Personal_Social_History2'] : old('Personal_Social_History2') }}"/>

                                            </div>
                                        </div>

                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Food_Allergies_and_Intolerances">Food Allergies and
                                                    Intolerances</label>
                                                <input placeholder="Food Allergies and Intolerances"
                                                       name="Food_Allergies_and_Intolerances" required
                                                       id="Food_Allergies_and_Intolerances" class="form-control"
                                                       value="{{ !empty($NutritionistHistoryEvaluationSection['Food_Allergies_and_Intolerances']) ? $NutritionistHistoryEvaluationSection['Food_Allergies_and_Intolerances'] : old('Food_Allergies_and_Intolerances') }}"/>

                                            </div>
                                        </div>
                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Appetite">Appetite</label>
                                                <input placeholder="Appetite" name="Appetite" required id="Appetite"
                                                       class="form-control"
                                                       value="{{ !empty($NutritionistHistoryEvaluationSection['Appetite']) ? $NutritionistHistoryEvaluationSection['Appetite'] : old('Appetite') }}"/>
                                            </div>
                                        </div>


                                        <div class="form-group col-md-12">
                                            <div class="form-group">
                                                <label for="Recent_Weight_Changes_Weight_History">Recent Weight Changes
                                                    &
                                                    Weight History</label>
                                                <input placeholder="Recent Weight Changes & Weight History"
                                                       name="Recent_Weight_Changes_Weight_History" required
                                                       id="Recent_Weight_Changes_Weight_History" class="form-control"
                                                       value="{{ !empty($NutritionistHistoryEvaluationSection['Recent_Weight_Changes_Weight_History']) ? $NutritionistHistoryEvaluationSection['Recent_Weight_Changes_Weight_History'] : old('Recent_Weight_Changes_Weight_History') }}"/>

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

                                <h4 class="mt-4">24- hour Dietary Recall</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Breakfast">Breakfast <span id="BreakfastAlert"></span></label>

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

                                        </div>
                                    </div>

                                    <div class="form-group col-md-12 d-none" id="showBreakFastDetail">
                                        <div class="form-group">
                                            <label for="breakfast_detail">Detail</label>
                                            <input placeholder="Detail" name="breakfast_detail" id="breakfast_detail"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['breakfast_detail'])) value="{{ $NutritionistHistoryEvaluationSection['breakfast_detail'] }}"
                                                   @else
                                                   value="{{ old('breakfast_detail') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Mid_day_Snack">Mid-day Snack</label>
                                            <select id="Mid_day_Snack" name="Mid_day_Snack" class="form-control"
                                                    onchange="showMidDaySnack()" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Mid_day_Snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Mid_day_Snack'] == 'Yes') selected
                                                        @elseif(old('Mid_day_Snack') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Mid_day_Snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Mid_day_Snack'] == 'No') selected
                                                        @elseif(old('Mid_day_Snack') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12 d-none" id="showMidDaySnackDetail">
                                        <div class="form-group">
                                            <label for="MidDaySnackDetail">Detail</label>
                                            <input placeholder="Detail" name="MidDaySnackDetail" id="MidDaySnackDetail"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['MidDaySnackDetail'])) value="{{ $NutritionistHistoryEvaluationSection['MidDaySnackDetail'] }}"
                                                   @else
                                                   value="{{ old('MidDaySnackDetail') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Lunch">Lunch <span id="LunchAlert"></span></label>
                                            <select id="Lunch" class="form-control" onchange="showLunchFunc()"
                                                    name="Lunch" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Lunch']) && $NutritionistHistoryEvaluationSection['Lunch'] == 'Yes') selected
                                                        @elseif(old('Lunch') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Lunch']) && $NutritionistHistoryEvaluationSection['Lunch'] == 'No') selected
                                                        @elseif(old('Lunch') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12 d-none" id="showlunchdetail">
                                        <div class="form-group">
                                            <label for="lunchDetail">Detail</label>
                                            <input placeholder="Detail" name="lunchDetail" id="lunchDetail"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['lunchDetail'])) value="{{ $NutritionistHistoryEvaluationSection['lunchDetail'] }}"
                                                   @else
                                                   value="{{ old('lunchDetail') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Evening_Snack">Evening Snack</label>
                                            <select id="Evening_Snack" class="form-control" name="Evening_Snack"
                                                    onchange="showEveningSnackFunc()" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Evening_Snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Evening_Snack'] == 'Yes') selected
                                                        @elseif(old('Evening_Snack') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Evening_Snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Evening_Snack'] == 'No') selected
                                                        @elseif(old('Evening_Snack') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12 d-none" id="showEveningSnackDetail">
                                        <div class="form-group">
                                            <label for="EveningSnackDetail">Detail</label>
                                            <input placeholder="Detail" name="EveningSnackDetail"
                                                   id="EveningSnackDetail"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['EveningSnackDetail'])) value="{{ $NutritionistHistoryEvaluationSection['EveningSnackDetail'] }}"
                                                   @else
                                                   value="{{ old('EveningSnackDetail') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Dinner">Dinner <span id="DinnerAlert"></span></label>
                                            <select id="Dinner" class="form-control" onchange="showDinnerFunc()"
                                                    name="Dinner" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Dinner']) && $NutritionistHistoryEvaluationSection['Dinner'] == 'Yes') selected
                                                        @elseif(old('Dinner') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Dinner']) && $NutritionistHistoryEvaluationSection['Dinner'] == 'No') selected
                                                        @elseif(old('Dinner') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12 d-none" id="showDinner">
                                        <div class="form-group">
                                            <label for="Dinner">Detail</label>
                                            <input placeholder="Detail" name="DinnerDetails" id="DinnerDetails"
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['DinnerDetails'])) value="{{ $NutritionistHistoryEvaluationSection['DinnerDetails'] }}"
                                                   @else
                                                   value="{{ old('DinnerDetails') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Bed_time_snack">Bed-time snack</label>
                                            <select id="Bed_time_snack" class="form-control" name="Bed_time_snack"
                                                    required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Bed_time_snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Bed_time_snack'] == 'Yes') selected
                                                        @elseif(old('Bed_time_snack') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Bed_time_snack']) &&
                                                                $NutritionistHistoryEvaluationSection['Bed_time_snack'] == 'No') selected
                                                        @elseif(old('Bed_time_snack') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Biochemical_Laboratory_test_Reports">Biochemical / Laboratory
                                                Test
                                                Reports</label>
                                            <input placeholder="Biochemical / Laboratory Test Reports"
                                                   name="Biochemical_Laboratory_test_Reports"
                                                   id="Biochemical_Laboratory_test_Reports" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Biochemical_Laboratory_test_Reports'])) value="{{ $NutritionistHistoryEvaluationSection['Biochemical_Laboratory_test_Reports'] }}"
                                                   @else
                                                   value="{{ old('Biochemical_Laboratory_test_Reports') }}" @endif />
                                        </div>
                                    </div>

                                </div>

                                <h4 class="mt-4">Clinical Examination</h4>

                                <h5 class="mt-4 text-center">Physical Appearance</h5>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Skin">Skin</label>
                                            <select id="Skin" class="form-control" name="Skin" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Skin']) && $NutritionistHistoryEvaluationSection['Skin'] == 'Normal') selected
                                                        @elseif(old('Skin') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Dry"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Skin']) && $NutritionistHistoryEvaluationSection['Skin'] == 'Dry') selected
                                                        @elseif(old('Skin') == 'Dry')
                                                        selected @endif>
                                                    Dry
                                                </option>
                                                <option value="Scaly"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Skin']) && $NutritionistHistoryEvaluationSection['Skin'] == 'Scaly') selected
                                                        @elseif(old('Skin') == 'Scaly')
                                                        selected @endif>
                                                    Scaly
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Eyes">Eyes</label>
                                            <select id="Eyes" name="Eyes" class="form-control" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Eyes']) && $NutritionistHistoryEvaluationSection['Eyes'] == 'Normal') selected
                                                        @elseif(old('Eyes') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Pale"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Eyes']) && $NutritionistHistoryEvaluationSection['Eyes'] == 'Pale') selected
                                                        @elseif(old('Eyes') == 'Pale')
                                                        selected @endif>
                                                    Pale
                                                </option>
                                                <option value="Redness"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Eyes']) && $NutritionistHistoryEvaluationSection['Eyes'] == 'Redness') selected
                                                        @elseif(old('Eyes') == 'Redness')
                                                        selected @endif>
                                                    Redness
                                                </option>
                                                <option value="Yellow"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Eyes']) && $NutritionistHistoryEvaluationSection['Eyes'] == 'Yellow') selected
                                                        @elseif(old('Eyes') == 'Yellow')
                                                        selected @endif>
                                                    Yellow
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Lips">Lips</label>
                                            <select id="Lips" name="Lips" class="form-control" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Lips']) && $NutritionistHistoryEvaluationSection['Lips'] == 'Normal') selected
                                                        @elseif(old('Lips') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Dry"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Lips']) && $NutritionistHistoryEvaluationSection['Lips'] == 'Dry') selected
                                                        @elseif(old('Lips') == 'Dry')
                                                        selected @endif>
                                                    Dry
                                                </option>
                                                <option value="Dark Colored"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Lips']) &&
                                                                $NutritionistHistoryEvaluationSection['Lips'] == 'Dark Colored') selected
                                                        @elseif(old('Lips') == 'Dark Colored')
                                                        selected @endif>
                                                    Dark Colored
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Nails">Nails</label>
                                            <select id="Nails" name="Nails" class="form-control" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Nails']) &&
                                                                $NutritionistHistoryEvaluationSection['Nails'] == 'Normal') selected
                                                        @elseif(old('Nails') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Brittle"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Nails']) &&
                                                                $NutritionistHistoryEvaluationSection['Nails'] == 'Brittle') selected
                                                        @elseif(old('Nails') == 'Brittle')
                                                        selected @endif>
                                                    Brittle
                                                </option>
                                                <option value="Translucent"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Nails']) &&
                                                                $NutritionistHistoryEvaluationSection['Nails'] == 'Translucent') selected
                                                        @elseif(old('Nails') == 'Translucent')
                                                        selected @endif>
                                                    Translucent
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Hair">Hair</label>
                                            <select id="Hair" name="Hair" class="form-control" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Hair']) && $NutritionistHistoryEvaluationSection['Hair'] == 'Normal') selected
                                                        @elseif(old('Hair') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Dry"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Hair']) && $NutritionistHistoryEvaluationSection['Hair'] == 'Dry') selected
                                                        @elseif(old('Hair') == 'Dry')
                                                        selected @endif>
                                                    Dry
                                                </option>
                                                <option value="Brittle"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Hair']) && $NutritionistHistoryEvaluationSection['Hair'] == 'Brittle') selected
                                                        @elseif(old('Hair') == 'Brittle')
                                                        selected @endif>
                                                    Brittle
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Scalp">Scalp</label>
                                            <select id="Scalp" name="Scalp" class="form-control" required>
                                                <option value="">Select</option>
                                                <option value="Normal"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Scalp']) &&
                                                                $NutritionistHistoryEvaluationSection['Scalp'] == 'Normal') selected
                                                        @elseif (old('Scalp') == 'Normal')
                                                        selected @endif>
                                                    Normal
                                                </option>
                                                <option value="Dry"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Scalp']) && $NutritionistHistoryEvaluationSection['Scalp'] == 'Dry') selected
                                                        @elseif (old('Scalp') == 'Dry')
                                                        selected @endif>
                                                    Dry
                                                </option>
                                                <option value="Scaly"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Scalp']) && $NutritionistHistoryEvaluationSection['Scalp'] == 'Scaly') selected
                                                        @elseif (old('Scalp') == 'Scaly')
                                                        selected @endif>
                                                    Scaly
                                                </option>
                                                <option value="Oily"
                                                        @if (!empty($NutritionistHistoryEvaluationSection['Scalp']) && $NutritionistHistoryEvaluationSection['Scalp'] == 'Oily') selected
                                                        @elseif (old('Scalp') == 'Oily')
                                                        selected @endif>
                                                    Oily
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                </div>


                                <h4 class="text-center mt-3">Diagnosis, Impression and Plan</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Problem_List1">Problem List</label>
                                            <input placeholder="Problem List" name="Problem_List1" id="Problem_List1"
                                                   required class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Problem_List1'])) value="{{ $NutritionistHistoryEvaluationSection['Problem_List1'] }}"
                                                   @else
                                                   value="{{ old('Problem_List1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Impression1">Impression</label>
                                            <input placeholder="Impression" name="Impression1" id="Impression1" required
                                                   class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Impression1'])) value="{{ $NutritionistHistoryEvaluationSection['Impression1'] }}"
                                                   @else
                                                   value="{{ old('Impression1') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Provisional_Diagnosis1">Provisional Diagnosis</label><br>
                                            @php
                                                $provisionalArray = [];
                                                if (
                                                    !empty(
                                                        $NutritionistHistoryEvaluationSection['Provisional_Diagnosis1']
                                                    )
                                                ) {
                                                    $provisionalArray = explode(
                                                        '|',
                                                        $NutritionistHistoryEvaluationSection['Provisional_Diagnosis1'],
                                                    );
                                                }
                                            @endphp
                                            <select id="Provisional_Diagnosis1" name="Provisional_Diagnosis1[]" required
                                                    class="form-control js-states select_multi py-3" multiple>

                                                @if (!empty($ICD10))
                                                    @foreach ($ICD10 as $ICD1)
                                                        @php

                                                            $ICD1_value = $ICD1['code'] . '-' . $ICD1['description'];

                                                        @endphp

                                                        <option value="{{ $ICD1_value }}"
                                                            {{ in_array($ICD1_value, $provisionalArray) ? 'selected' : '' }}>
                                                            {{ $ICD1_value }}</option>
                                                    @endforeach
                                                @else
                                                    <option value="H10.9 Unspecified conjunctivitis"
                                                        {{ in_array('H10.9 Unspecified conjunctivitis', $provisionalArray) ? 'selected' : '' }}>
                                                        H10.9 Unspecified conjunctivitis
                                                    </option>
                                                    <option value="H10.32 Unspecified acute conjunctivitis, left eye"
                                                        {{ in_array('H10.32 Unspecified acute conjunctivitis, left eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H10.32 Unspecified acute conjunctivitis, left eye
                                                    </option>
                                                    <option value="H52.11 Myopia, right eye"
                                                        {{ in_array('H52.11 Myopia, right eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.11 Myopia, right eye
                                                    </option>
                                                    <option value="H52.12 Myopia, left eye"
                                                        {{ in_array('H52.12 Myopia, left eye', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.12 Myopia, left eye
                                                    </option>
                                                    <option value="H52.13 Myopia, bilateral"
                                                        {{ in_array('H52.13 Myopia, bilateral', $provisionalArray) ? 'selected' : '' }}>
                                                        H52.13 Myopia, bilateral
                                                    </option>
                                                @endif

                                            </select>
                                        </div>

                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="General_Advice1">General Advice & Management Plan</label>
                                            <input placeholder="General Advice & Management Plan" name="General_Advice1"
                                                   id="General_Advice1" class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['General_Advice1'])) value="{{ $NutritionistHistoryEvaluationSection['General_Advice1'] }}"
                                                   @else
                                                   value="{{ old('General_Advice1') }}" @endif />
                                        </div>
                                    </div>


                                </div>

                                <h4 class="mt-4 text-center">Diet Plan</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="diet_breakfast">Breakfast</label>
                                            <input placeholder="Breakfast" name="diet_breakfast" id="diet_breakfast"
                                                   class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['diet_breakfast'])) value="{{ $NutritionistHistoryEvaluationSection['diet_breakfast'] }}"
                                                   @else
                                                   value="{{ old('diet_breakfast') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="diet_snack">Snack</label>
                                            <input placeholder="Snack" name="diet_snack" id="diet_snack"
                                                   class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['diet_snack'])) value="{{ $NutritionistHistoryEvaluationSection['diet_snack'] }}"
                                                   @else
                                                   value="{{ old('diet_snack') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="diet_lunch">Lunch</label>
                                            <input placeholder="Lunch" name="diet_lunch" id="diet_lunch"
                                                   class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['diet_lunch'])) value="{{ $NutritionistHistoryEvaluationSection['diet_lunch'] }}"
                                                   @else
                                                   value="{{ old('diet_lunch') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="diet_dinner">Dinner</label>
                                            <input placeholder="Dinner" name="diet_dinner" id="diet_dinner"
                                                   class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['diet_dinner'])) value="{{ $NutritionistHistoryEvaluationSection['diet_dinner'] }}"
                                                   @else
                                                   value="{{ old('diet_dinner') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="diet_bedtime">Bedtime</label>
                                            <input type="time" placeholder="Bedtime" name="diet_bedtime"
                                                   id="diet_bedtime" class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['diet_bedtime'])) value="{{ $NutritionistHistoryEvaluationSection['diet_bedtime'] }}"
                                                   @else
                                                   value="{{ old('diet_bedtime') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <hr>


                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Required1">Follow-up Required</label>
                                            <select id="Follow_up_Required1" name="Follow_up_Required1"
                                                    class="form-control" onchange="followUp1()" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Follow_up_Required1']) &&
                                                                $NutritionistHistoryEvaluationSection['Follow_up_Required1'] == 'Yes') selected
                                                        @elseif(old('Follow_up_Required1') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (
                                                            !empty($NutritionistHistoryEvaluationSection['Follow_up_Required1']) &&
                                                                $NutritionistHistoryEvaluationSection['Follow_up_Required1'] == 'No') selected
                                                        @elseif(old('Follow_up_Required1') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                </div>

                                <div class="form-row d-none" id="follow_up_show1">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Reason_for_Follow_up1">Reason for Follow-up</label>
                                            <input placeholder="Reason for Follow-up" name="Reason_for_Follow_up1"
                                                   id="Reason_for_Follow_up1" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Reason_for_Follow_up1'])) value="{{ $NutritionistHistoryEvaluationSection['Reason_for_Follow_up1'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Follow_up1') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Date1">Follow-up Date</label>
                                            <input type="date" placeholder="Reason for Follow-up"
                                                   name="Follow_up_Date1" id="Follow_up_Date1" class="form-control"
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Follow_up_Date1'])) value="{{ $NutritionistHistoryEvaluationSection['Follow_up_Date1'] }}"
                                                   @else
                                                   value="{{ old('Follow_up_Date1') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <h3>Refferals</h3>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="internal_referrals1">Internal Referrals</label>

                                            <select id="internal_referrals1" name="internal_referrals1[]" required
                                                    class="form-control js-states select_multi py-3" multiple>


                                                @php
                                                    $selectedValues = [];
                                                    if (
                                                        !empty(
                                                            $NutritionistHistoryEvaluationSection['internal_referrals1']
                                                        )
                                                    ) {
                                                        $selectedValues = explode(
                                                            '|',
                                                            $NutritionistHistoryEvaluationSection[
                                                                'internal_referrals1'
                                                            ] ?? '',
                                                        );
                                                    }
                                                @endphp


                                                <option value="Nutritionist"
                                                        @if (in_array('Nutritionist', $selectedValues)) selected @endif>
                                                    Nutritionist
                                                </option>
                                                <option value="Psychologist"
                                                        @if (in_array('Psychologist', $selectedValues)) selected @endif>
                                                    Psychologist
                                                </option>
                                                <option value="School Health Physician"
                                                        @if (in_array('School Health Physician', $selectedValues)) selected @endif>
                                                    School Health
                                                    Physician
                                                </option>
                                                <option value="Not Required"
                                                        @if (in_array('Not Required', $selectedValues)) selected @endif>
                                                    Not Required
                                                </option>
                                              
                                                
                                            </select>


                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="external_referrals1">External Referrals</label>
                                            <select id="external_referrals1" name="external_referrals1[]" required
                                                    class="form-control js-states select_multi py-3" multiple
                                                    onchange="showReasonForReferral1()">
                                                @php
                                                    $selectedValues = [];
                                                    if (
                                                        !empty(
                                                            $NutritionistHistoryEvaluationSection['external_referrals1']
                                                        )
                                                    ) {
                                                        $selectedValues = explode(
                                                            '|',
                                                            $NutritionistHistoryEvaluationSection[
                                                                'external_referrals1'
                                                            ] ?? '',
                                                        );
                                                    }
                                                @endphp



                                                @if (!empty($ExternalReferralList))
                                                    @foreach ($ExternalReferralList as $ExternalReferralLis)
                                                        <option value="{{ $ExternalReferralLis['name'] }}"
                                                                @if (in_array($ExternalReferralLis['name'], $selectedValues)) selected @endif>
                                                            {{ $ExternalReferralLis['name'] }}</option>
                                                    @endforeach
                                                @else
                                                    <option value="Allery and Immunology"
                                                            @if (in_array('Allery and Immunology', $selectedValues)) selected @endif>
                                                        Allery and Immunology
                                                    </option>
                                                    <option value="Cardiology"
                                                            @if (in_array('Cardiology', $selectedValues)) selected @endif>
                                                        Cardiology
                                                    </option>
                                                    <option value="Clinical Psychology"
                                                            @if (in_array('Clinical Psychology', $selectedValues)) selected @endif>
                                                        Clinical Psychology
                                                    </option>
                                                    <option value="Dentistry"
                                                            @if (in_array('Dentistry', $selectedValues)) selected @endif>
                                                        Dentistry
                                                    </option>
                                                    <option value="Dermatology"
                                                            @if (in_array('Dermatology', $selectedValues)) selected @endif>
                                                        Dermatology
                                                    </option>
                                                @endif
                                            </select>
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12 d-none" id="reasonForReferralSection1">
                                        <div class="form-group">
                                            <label for="Reason_for_Referral1">Reason for Referral</label>
                                            <input placeholder="Reason for Referral" name="Reason_for_Referral1"
                                                   id="Reason_for_Referral1" class="form-control" required
                                                   @if (!empty($NutritionistHistoryEvaluationSection['Reason_for_Referral1'])) value="{{ $NutritionistHistoryEvaluationSection['Reason_for_Referral1'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Referral1') }}" @endif />
                                        </div>
                                    </div>

                                </div>


                                {{-- <a href="{{ Route('StudentBiodata') }}">
                                <button type="button" class="btn btn-primary prevStep">Previous</button>
                            </a>

                            <button type="submit" name="submit" class="btn btn-primary">Submit</button> --}}


                            </form>

                        </div>


                        <div
                            class="tab-pane fade @if (!empty($PsychologistHistoryAssessmentSection)) active show @endif"
                            id="contact" role="tabpanel" aria-labelledby="contact-tab">

                            <form id="multiStepForm"
                                  action="{{ route('PsychologistHistoryAssessmentSection') }}/{{ $StudentBiodataId }}}"
                                  method="POST">
                                @csrf

                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h3 class="text-center mt-4">Psychologist History & Assessment Section</h3>

                                <div class="form-row mt-5">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Identifying_Personal_Information">Identifying Personal
                                                Information</label>
                                            <input placeholder="Identifying Personal Information"
                                                   name="Identifying_Personal_Information"
                                                   id="Identifying_Personal_Information" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Identifying_Personal_Information'])) value="{{ $PsychologistHistoryAssessmentSection['Identifying_Personal_Information'] }}"
                                                   @else
                                                   value="{{ old('Identifying_Personal_Information') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Referral_Source">Referral Source</label>
                                            <input placeholder="Referral Source" name="Referral_Source"
                                                   id="Referral_Source" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Referral_Source'])) value="{{ $PsychologistHistoryAssessmentSection['Referral_Source'] }}"
                                                   @else
                                                   value="{{ old('Referral_Source') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Chief_Complaints3">Chief Complaints</label>
                                            <input placeholder="Chief Complaints" name="Chief_Complaints3"
                                                   id="Chief_Complaints3" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Chief_Complaints3'])) value="{{ $PsychologistHistoryAssessmentSection['Chief_Complaints3'] }}"
                                                   @else
                                                   value="{{ old('Chief_Complaints3') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="History_of_Presenting_Complaints2">History of Presenting
                                                Complaints</label>
                                            <input placeholder="History of Presenting Complaints"
                                                   name="History_of_Presenting_Complaints2"
                                                   id="History_of_Presenting_Complaints2" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['History_of_Presenting_Complaints2'])) value="{{ $PsychologistHistoryAssessmentSection['History_of_Presenting_Complaints2'] }}"
                                                   @else
                                                   value="{{ old('History_of_Presenting_Complaints2') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Investigations_Laboratory_Test_Reports2">Investigations /
                                                Laboratory Test Reports</label>
                                            <input placeholder="Investigations / Laboratory Test Reports"
                                                   name="Investigations_Laboratory_Test_Reports2"
                                                   id="Investigations_Laboratory_Test_Reports2" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Investigations_Laboratory_Test_Reports2'])) value="{{ $PsychologistHistoryAssessmentSection['Investigations_Laboratory_Test_Reports2'] }}"
                                                   @else
                                                   value="{{ old('Investigations_Laboratory_Test_Reports2') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Past_Medical_Psychiatric_History">Past Medical & Psychiatric
                                                History</label>
                                            <input placeholder="Past Medical & Psychiatric History"
                                                   name="Past_Medical_Psychiatric_History"
                                                   id="Past_Medical_Psychiatric_History" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Past_Medical_Psychiatric_History'])) value="{{ $PsychologistHistoryAssessmentSection['Past_Medical_Psychiatric_History'] }}"
                                                   @else
                                                   value="{{ old('Past_Medical_Psychiatric_History') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Medication_History_Allergies">Medication History &
                                                Allergies</label>
                                            <input placeholder="Medication History & Allergies"
                                                   name="Medication_History_Allergies" id="Medication_History_Allergies"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Medication_History_Allergies'])) value="{{ $PsychologistHistoryAssessmentSection['Medication_History_Allergies'] }}"
                                                   @else
                                                   value="{{ old('Past_Medical_Psychiatric_History') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Family_History3">Family History</label>
                                            <input placeholder="Family History" name="Family_History3"
                                                   id="Family_History3" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Medication_History_Allergies'])) value="{{ $PsychologistHistoryAssessmentSection['Medication_History_Allergies'] }}"
                                                   @else
                                                   value="{{ old('Past_Medical_Psychiatric_History') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Personal_Social_History3">Personal & Social History</label>
                                            <input placeholder="Personal & Social History"
                                                   name="Personal_Social_History3" id="Personal_Social_History3"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Personal_Social_History3'])) value="{{ $PsychologistHistoryAssessmentSection['Personal_Social_History3'] }}"
                                                   @else
                                                   value="{{ old('Personal_Social_History3') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>

                                <h4 class="text-center mt-4">Mental Status Examination</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Appearance_Behavior">Appearance & Behavior</label>
                                            <input placeholder="Appearance & Behavior" name="Appearance_Behavior"
                                                   id="Appearance_Behavior" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Appearance_Behavior'])) value="{{ $PsychologistHistoryAssessmentSection['Appearance_Behavior'] }}"
                                                   @else
                                                   value="{{ old('Appearance_Behavior') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Attitude_toward_the_examiner">Attitude toward the
                                                examiner</label>
                                            <input placeholder="Attitude toward the examiner"
                                                   name="Attitude_toward_the_examiner" id="Attitude_toward_the_examiner"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Attitude_toward_the_examiner'])) value="{{ $PsychologistHistoryAssessmentSection['Attitude_toward_the_examiner'] }}"
                                                   @else
                                                   value="{{ old('Attitude_toward_the_examiner') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Speech">Speech</label>
                                            <input placeholder="Speech" name="Speech" id="Speech"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Speech'])) value="{{ $PsychologistHistoryAssessmentSection['Speech'] }}"
                                                   @else
                                                   value="{{ old('Attitude_toward_the_examiner') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Mood">Mood</label>
                                            <input placeholder="Mood" name="Mood" id="Mood"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Mood'])) value="{{ $PsychologistHistoryAssessmentSection['Mood'] }}"
                                                   @else
                                                   value="{{ old('Mood') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Affect">Affect</label>
                                            @php
                                                $selectedValues = [];
                                                if (!empty($PsychologistHistoryAssessmentSection['Affect'])) {
                                                    $selectedValues = explode(
                                                        '|',
                                                        $PsychologistHistoryAssessmentSection['Affect'],
                                                    );
                                                }
                                            @endphp

                                            <select class="form-control" id="Affect" name="Affect">
                                                <option value="Expansive (Contagious)"
                                                        @if (in_array('Expansive (Contagious)', $selectedValues)) selected @endif>
                                                    Expansive (Contagious)
                                                </option>
                                                <option value="Euthymic (Normal)"
                                                        @if (in_array('Euthymic (Normal)', $selectedValues)) selected @endif>
                                                    Euthymic (Normal)
                                                </option>
                                                <option value="Constricted (Limited Variation)"
                                                        @if (in_array('Constricted (Limited Variation)', $selectedValues)) selected @endif>
                                                    Constricted (Limited Variation)
                                                </option>
                                                <option value="Blunted (Minimal Variation)"
                                                        @if (in_array('Blunted (Minimal Variation)', $selectedValues)) selected @endif>
                                                    Blunted (Minimal Variation)
                                                </option>
                                                <option value="Flat (No Variation)"
                                                        @if (in_array('Flat (No Variation)', $selectedValues)) selected @endif>
                                                    Flat (No Variation)
                                                </option>
                                                <option value="Inappropriate"
                                                        @if (in_array('Inappropriate', $selectedValues)) selected @endif>
                                                    Inappropriate
                                                </option>
                                            </select>

                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Thought_process_content">Thought Process & Content</label>
                                            <input placeholder="Thought Process & Content"
                                                   name="Thought_process_content" id="Thought_process_content"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Thought_process_content'])) value="{{ $PsychologistHistoryAssessmentSection['Thought_process_content'] }}"
                                                   @else
                                                   value="{{ old('Thought_process_content') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Perceptions">Perceptions</label>
                                            <input placeholder="Perceptions" name="Perceptions" id="Perceptions"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Perceptions'])) value="{{ $PsychologistHistoryAssessmentSection['Perceptions'] }}"
                                                   @else
                                                   value="{{ old('Perceptions') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Delusions">Delusions</label>
                                            <input placeholder="Delusions" name="Delusions" id="Delusions"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Delusions'])) value="{{ $PsychologistHistoryAssessmentSection['Delusions'] }}"
                                                   @else
                                                   value="{{ old('Delusions') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Cognitive_Function">Cognitive Function</label>
                                            <input placeholder="Cognitive Function" name="Cognitive_Function"
                                                   id="Cognitive_Function" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Cognitive_Function'])) value="{{ $PsychologistHistoryAssessmentSection['Cognitive_Function'] }}"
                                                   @else
                                                   value="{{ old('Cognitive_Function') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Insight">Insight</label>
                                            <input placeholder="Insight" name="Insight" id="Insight"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Insight'])) value="{{ $PsychologistHistoryAssessmentSection['Insight'] }}"
                                                   @else
                                                   value="{{ old('Insight') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Judgement">Judgement</label>
                                            <input placeholder="Judgement" name="Judgement" id="Judgement"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Judgement'])) value="{{ $PsychologistHistoryAssessmentSection['Judgement'] }}"
                                                   @else
                                                   value="{{ old('Judgement') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Impulsivity">Impulsivity</label>
                                            <input placeholder="Impulsivity" name="Impulsivity" id="Impulsivity"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Impulsivity'])) value="{{ $PsychologistHistoryAssessmentSection['Impulsivity'] }}"
                                                   @else
                                                   value="{{ old('Impulsivity') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Reliability">Reliability</label>
                                            <input placeholder="Reliability" name="Reliability" id="Reliability"
                                                   class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Reliability'])) value="{{ $PsychologistHistoryAssessmentSection['Reliability'] }}"
                                                   @else
                                                   value="{{ old('Reliability') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" alt=""/>
                                <h4 class="text-center mt-3">Diagnosis, Impression and Plan</h4>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Problem_List2">Problem List</label>
                                            <input placeholder="Problem List" name="Problem_List2" id="Problem_List2"
                                                   required class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Problem_List2'])) value="{{ $PsychologistHistoryAssessmentSection['Problem_List2'] }}"
                                                   @else
                                                   value="{{ old('Problem_List2') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Impression2">Impression</label>
                                            <input placeholder="Impression" name="Impression2" id="Impression2"
                                                   required class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Impression2'])) value="{{ $PsychologistHistoryAssessmentSection['Impression2'] }}"
                                                   @else
                                                   value="{{ old('Impression2') }}" @endif />
                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Provisional_Diagnosis2">Provisional Diagnosis</label><br>
                                            <select name="Provisional_Diagnosis2[]" id="Provisional_Diagnosis2" required
                                                    class="form-control js-states select_multi py-3" multiple>

                                                @php
                                                    $selectedDiagnosis = [];
                                                    if (
                                                        !empty(
                                                            $PsychologistHistoryAssessmentSection[
                                                                'Provisional_Diagnosis2'
                                                            ]
                                                        )
                                                    ) {
                                                        $selectedDiagnosis = explode(
                                                            '|',
                                                            $PsychologistHistoryAssessmentSection[
                                                                'Provisional_Diagnosis2'
                                                            ],
                                                        );
                                                    }
                                                @endphp


                                                @if (!empty($ICD10))
                                                    @foreach ($ICD10 as $ICD1)
                                                        @php

                                                            $ICD1_value = $ICD1['code'] . '-' . $ICD1['description'];

                                                        @endphp

                                                        <option value="{{ $ICD1_value }}"
                                                            {{ in_array($ICD1_value, $selectedDiagnosis) ? 'selected' : '' }}>
                                                            {{ $ICD1_value }}</option>
                                                    @endforeach
                                                @else
                                                    <option
                                                        value="H10.9 Unspecified conjunctivitis"{{ in_array('H10.9 Unspecified conjunctivitis', $selectedDiagnosis) ? ' selected' : '' }}>
                                                        H10.9 Unspecified conjunctivitis
                                                    </option>
                                                    <option
                                                        value="H10.32 Unspecified acute conjunctivitis, left eye"{{ in_array('H10.32 Unspecified acute conjunctivitis, left eye', $selectedDiagnosis) ? ' selected' : '' }}>
                                                        H10.32 Unspecified acute conjunctivitis, left eye
                                                    </option>
                                                    <option
                                                        value="H52.11 Myopia, right eye"{{ in_array('H52.11 Myopia, right eye', $selectedDiagnosis) ? ' selected' : '' }}>
                                                        H52.11 Myopia, right eye
                                                    </option>
                                                    <option
                                                        value="H52.12 Myopia, left eye"{{ in_array('H52.12 Myopia, left eye', $selectedDiagnosis) ? ' selected' : '' }}>
                                                        H52.12 Myopia, left eye
                                                    </option>
                                                    <option
                                                        value="H52.13 Myopia, bilateral"{{ in_array('H52.13 Myopia, bilateral', $selectedDiagnosis) ? ' selected' : '' }}>
                                                        H52.13 Myopia, bilateral
                                                    </option>
                                                @endif
                                            </select>


                                        </div>
                                    </div>

                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="General_Advice2">General Advice & Management Plan</label>
                                            <input placeholder="General Advice & Management Plan" name="General_Advice2"
                                                   id="General_Advice2" class="form-control" required
                                                   @if (!empty($PsychologistHistoryAssessmentSection['General_Advice2'])) value="{{ $PsychologistHistoryAssessmentSection['General_Advice2'] }}"
                                                   @else
                                                   value="{{ old('General_Advice2') }}" @endif />
                                        </div>
                                    </div>


                                </div>


                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Required2">Follow-up Required</label>
                                            <select name="Follow_up_Required2" id="Follow_up_Required2"
                                                    class="form-control" onchange="followUp2()" required>
                                                <option value="">Select</option>
                                                <option value="Yes"
                                                        @if (
                                                            !empty($PsychologistHistoryAssessmentSection['Follow_up_Required2']) &&
                                                                $PsychologistHistoryAssessmentSection['Follow_up_Required2'] == 'Yes') selected
                                                        @elseif(old('Follow_up_Required2') == 'Yes')
                                                        selected @endif>
                                                    Yes
                                                </option>
                                                <option value="No"
                                                        @if (
                                                            !empty($PsychologistHistoryAssessmentSection['Follow_up_Required2']) &&
                                                                $PsychologistHistoryAssessmentSection['Follow_up_Required2'] == 'No') selected
                                                        @elseif(old('Follow_up_Required2') == 'No')
                                                        selected @endif>
                                                    No
                                                </option>
                                            </select>
                                        </div>
                                    </div>
                                </div>

                                <div class="form-row d-none" id="follow_up_show2">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Reason_for_Follow_up2">Reason for Follow-up</label>
                                            <input placeholder="Reason for Follow-up" name="Reason_for_Follow_up2"
                                                   id="Reason_for_Follow_up2" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Reason_for_Follow_up2'])) value="{{ $PsychologistHistoryAssessmentSection['Reason_for_Follow_up2'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Follow_up2') }}" @endif />
                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="Follow_up_Date2">Follow-up Date</label>
                                            <input type="date" placeholder="Reason for Follow-up"
                                                   name="Follow_up_Date2" id="Follow_up_Date2" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Follow_up_Date2'])) value="{{ $PsychologistHistoryAssessmentSection['Follow_up_Date2'] }}"
                                                   @else
                                                   value="{{ old('Follow_up_Date2') }}" @endif />
                                        </div>
                                    </div>
                                </div>

                                <h3>Refferals</h3>

                                <div class="form-row">
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="internal_referrals2">Internal Referrals</label>
                                            <select name="internal_referrals2[]" id="internal_referrals2"
                                                    class="form-control js-states select_multi py-3" multiple>
                                                @php
                                                    $selectedValues = [];
                                                    if (
                                                        !empty(
                                                            $PsychologistHistoryAssessmentSection['internal_referrals2']
                                                        )
                                                    ) {
                                                        $selectedValues = explode(
                                                            '|',
                                                            $PsychologistHistoryAssessmentSection[
                                                                'internal_referrals2'
                                                            ] ?? '',
                                                        );
                                                    }
                                                @endphp

                                                <option value="Nutritionist"
                                                        @if (in_array('Nutritionist', $selectedValues)) selected @endif>
                                                    Nutritionist
                                                </option>
                                                <option value="Psychologist"
                                                        @if (in_array('Psychologist', $selectedValues)) selected @endif>
                                                    Psychologist
                                                </option>
                                                <option value="School Health Physician"
                                                        @if (in_array('School Health Physician', $selectedValues)) selected @endif>
                                                    School Health
                                                    Physician
                                                </option>
                                                <option value="Not Required"
                                                        @if (in_array('Not Required', $selectedValues)) selected @endif>
                                                    Not Required
                                                </option>
                                                <option value="Teacher"
                                                @if (in_array('Teacher', $selectedValues)) selected @endif>Teacher
                                            </option>

                                            </select>


                                        </div>
                                    </div>
                                    <div class="form-group col-md-12">
                                        <div class="form-group">
                                            <label for="external_referrals2">External Referrals</label>
                                            <select name="external_referrals2[]" id="external_referrals2"
                                                    class="form-control js-states select_multi py-3" multiple
                                                    onchange="showReasonForReferral2()">
                                                @php
                                                    $selectedValues = !empty(
                                                        $PsychologistHistoryAssessmentSection['external_referrals2']
                                                    )
                                                        ? explode(
                                                            '|',
                                                            $PsychologistHistoryAssessmentSection[
                                                                'external_referrals2'
                                                            ],
                                                        )
                                                        : [];
                                                @endphp



                                                @if (!empty($ExternalReferralList))
                                                    @foreach ($ExternalReferralList as $ExternalReferralLis)
                                                        <option value="{{ $ExternalReferralLis['name'] }}"
                                                                @if (in_array($ExternalReferralLis['name'], $selectedValues)) selected @endif>
                                                            {{ $ExternalReferralLis['name'] }}</option>
                                                    @endforeach
                                                @else
                                                    <option
                                                        value="Allery and Immunology"{{ in_array('Allery and Immunology', $selectedValues) ? ' selected' : '' }}>
                                                        Allery and Immunology
                                                    </option>
                                                    <option
                                                        value="Cardiology"{{ in_array('Cardiology', $selectedValues) ? ' selected' : '' }}>
                                                        Cardiology
                                                    </option>
                                                    <option
                                                        value="Clinical Psychology"{{ in_array('Clinical Psychology', $selectedValues) ? ' selected' : '' }}>
                                                        Clinical Psychology
                                                    </option>
                                                    <option
                                                        value="Dentistry"{{ in_array('Dentistry', $selectedValues) ? ' selected' : '' }}>
                                                        Dentistry
                                                    </option>
                                                    <option
                                                        value="Dermatology"{{ in_array('Dermatology', $selectedValues) ? ' selected' : '' }}>
                                                        Dermatology
                                                    </option>
                                                @endif
                                            </select>

                                        </div>
                                    </div>
                                    <div class="form-group col-md-12 d-none" id="reasonForReferralSection2">
                                        <div class="form-group">
                                            <label for="Reason_for_Referral2">Reason for Referral</label>
                                            <input placeholder="Reason for Referral" name="Reason_for_Referral2"
                                                   id="Reason_for_Referral2" class="form-control"
                                                   @if (!empty($PsychologistHistoryAssessmentSection['Reason_for_Referral2'])) value="{{ $PsychologistHistoryAssessmentSection['Reason_for_Referral2'] }}"
                                                   @else
                                                   value="{{ old('Reason_for_Referral2') }}" @endif />
                                        </div>
                                    </div>

                                </div>


                                {{--
                            <a href="{{ Route('StudentBiodata') }}">
                                <button type="button" class="btn btn-primary prevStep">Previous</button>
                            </a>

                            <button type="submit" name="submit" class="btn btn-primary">Submit</button> --}}


                            </form>


                        </div>


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

        </div>

        {{-- <a href="{{Route('generate.pdf')}}/{{$StudentBiodata['id']}}"  class="btn btn-primary ">Print</a> --}}


    </div>
<div class="bg_drop">
    <div class="preloader-inner">
        <div class="sk-chase">
            <div class="sk-chase-dot"></div>
            <div class="sk-chase-dot"></div>
            <div class="sk-chase-dot"></div>
            <div class="sk-chase-dot"></div>
            <div class="sk-chase-dot"></div>
            <div class="sk-chase-dot"></div>
        </div>
    </div>
</div>
    <div class="modal fade" id="sendMailModal" tabindex="-1" aria-labelledby="sendMailModalLabel" data-keyboard="false" data-backdrop="static"

         aria-hidden="true">
        <div class="modal-dialog modal-dialog-centered">
            <div class="modal-content">
                <div class="modal-header">
                    <h5 class="modal-title" id="sendMailModalLabel">Send Mail</h5>
                    <button type="button" class="close text-white" data-dismiss="modal" aria-label="Close">
                        <span aria-hidden="true">&times;</span>
                    </button>
                </div>
                <div class="modal-body">


                    <form id="sendMailForm" action="{{ route('SendEmail') }}" method="post">
                        @csrf
                        <div class="form-group">
                            <label for="to">To</label>
                            <input type="email" name="to" class="form-control" placeholder="To" value="{{$SchoolEmail}}" readonly required>
                            {{-- <input type="email" name="to" class="form-control" placeholder="To" required> --}}
                        </div>
                        <div class="form-group">
                            <div class="form-group">
                                <label for="cc">CC</label>
                                <input type="text" name="cc" class="form-control" placeholder="CC" required>
                            </div>
                            <div class="form-group">
                                <label for="subject">Subject</label>
                                <input type="text" name="subject" class="form-control" placeholder="Subject"
                                       required>
                            </div>
                            <label for="message">Message</label>
                            <textarea name="message" id="message" class="form-control" cols="30" rows="10"
                                      placeholder="Message" required></textarea>
                        </div>
                        <input type="hidden" id="pdfPath" name="pdfPath" value="">
                        <button type="submit" id="sendButton" class="btn btn-secondary">
                            <span class="spinner-border spinner-border-sm d-none" role="status"
                                  aria-hidden="true"></span>
                            Send
                        </button>


                        <button type="button" class="close bt-danger" data-dismiss="modal" aria-label="Close">
                            Close
                        </button>
                    </form>


                </div>

            </div>
        </div>
    </div>
    <img src="{{ asset('admin/images/bicphs_logo_new.png') }}" class="img-fluid pdfLogo" id="pdfLogo" alt=""/>
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