171 lines
10 KiB
PHP
171 lines
10 KiB
PHP
@extends('layouts.app')
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@section('content-header')
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<div class="content-header">
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<div class="container-fluid">
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<div class="row mb-2">
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<div class="col-sm-6">
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<h1 class="m-0">Tambah Pasien</h1>
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</div>
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<div class="col-sm-6">
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<ol class="breadcrumb float-sm-right">
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<li class="breadcrumb-item"><a href="#">Home</a></li>
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<li class="breadcrumb-item active">Tambah Pasien</li>
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</ol>
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</div>
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</div>
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</div>
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</div>
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@endsection
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@section('main-content')
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<div class="row">
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<div class="col-12">
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<div class="card card-primary">
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<div class="card-header">
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<h3 class="card-title">Data Pasien</h3>
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</div>
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<form action="{{ route('patient-management.store') }}" method="POST">
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@csrf
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<div class="card-body" style="padding-bottom: 0.5rem">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label>NIK <strong class="text-danger">*</strong></label>
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<input name="identity_number" type="number" class="form-control"
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placeholder="Masukan NIK" value="{{ old('identity_number') }}" required>
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@error('identity_number')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Nama Depan <strong class="text-danger">*</strong></label>
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<input name="first_name" type="text" class="form-control"
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placeholder="Masukan Nama Depan" value="{{ old('first_name') }}" required>
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@error('first_name')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Nama Belakang <strong class="text-danger">*</strong></label>
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<input name="last_name" type="text" class="form-control"
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placeholder="Masukan Nama Belakang" value="{{ old('last_name') }}" required>
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@error('last_name')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Tanggal Lahir <strong class="text-danger">*</strong></label>
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<input name="birth_date" type="date" class="form-control" placeholder="Tanggal Lahir"
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value="{{ old('birth_date') }}" required>
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@error('birth_date')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Jenis Kelamin <strong class="text-danger">*</strong></label>
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<select name="gender" class="form-control">
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<option value="">-- Pilih --</option>
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<option value="L" {{ old('gender') == 'L' ? 'selected' : '' }}>Laki-Laki
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</option>
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<option value="P" {{ old('gender') == 'P' ? 'selected' : '' }}>Perempuan
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</option>
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</select>
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@error('gender')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>No. HP <strong class="text-danger">*</strong></label>
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<input name="phone_number" type="text" class="form-control" placeholder="No. HP"
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value="{{ old('phone_number') }}" required>
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@error('phone_number')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Contact Email <strong class="text-danger">*</strong></label>
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<input name="email" type="email" class="form-control" placeholder="Masukan Email"
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value="{{ old('email') }}" required>
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@error('email')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label>Golongan Darah <strong class="text-danger">*</strong></label>
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<select name="blood_type" class="form-control">
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<option value="">-- Pilih --</option>
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<option value="A" {{ old('blood_type') == 'A' ? 'selected' : '' }}>A </option>
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<option value="B" {{ old('blood_type') == 'B' ? 'selected' : '' }}>B
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</option>
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<option value="AB" {{ old('blood_type') == 'AB' ? 'selected' : '' }}>AB
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</option>
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<option value="O" {{ old('blood_type') == 'O' ? 'selected' : '' }}>O
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</option>
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<option value="Lainnya" {{ old('blood_type') == 'Lainnya' ? 'selected' : '' }}>
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Lainnya
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</option>
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</select>
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@error('gender')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Alamat <strong class="text-danger">*</strong></label>
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<textarea class="form-control" name="address" cols="20" rows="3" placeholder="Masukan Alamat" required>{{ old('address') }}</textarea>
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@error('address')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Alergi: <strong class="text-danger">*</strong></label>
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<textarea class="form-control" name="allergies" cols="20" rows="3" placeholder="Sebutkan alergi jika ada"
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required>{{ old('allergies') }}</textarea>
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@error('allergies')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Konsumsi Obat Saat Ini: <strong class="text-danger">*</strong></label>
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<textarea class="form-control" name="current_medicines" cols="20" rows="3"
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placeholder="Obat yang dikonsumsi saat ini, contoh : bodrex, almodipine" required>{{ old('current_medicines') }}</textarea>
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@error('current_medicines')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Histori Medis: <strong class="text-danger">*</strong></label>
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<textarea class="form-control" name="medical_history" cols="20" rows="3"
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placeholder="Histori medis pasien" required>{{ old('medical_history') }}</textarea>
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@error('medical_history')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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</div>
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</div>
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</div>
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<span class="text-muted float-start ml-4">
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<strong class="text-danger">*</strong> Wajib Diisi
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</span>
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<div class="card-footer mt-2">
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<button type="button" class="btn btn-primary" onclick="history.back()">Kembali</button>
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<button type="submit" class="btn btn-success">Submit</button>
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</div>
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</form>
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</div>
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</div>
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</div>
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@endsection
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@push('scripts')
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@if (session('success'))
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<script>
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document.addEventListener('DOMContentLoaded', function() {
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Toast.fire({
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icon: 'success',
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title: "{{ session('success') }}",
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});
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});
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</script>
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@endif
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@endpush
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