Debian
187 lines
9.1 KiB
PHP
187 lines
9.1 KiB
PHP
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<meta http-equiv="X-UA-Compatible" content="ie=edge">
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<link rel="shortcut icon" href="{{ asset('/asset/svg/logo.svg') }}" />
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<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/5.3.0/css/bootstrap.min.css">
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<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.9.0/css/bootstrap-datepicker.min.css">
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<link href="{{ asset('/asset/main.css') }}" rel="stylesheet" />
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<link href="{{ asset('/assets/bootstrap/css/bootstrap.min.css') }}" rel="stylesheet" />
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<link rel="stylesheet" href="https://fonts.googleapis.com/css2?family=Material+Symbols+Outlined:opsz,wght,FILL,GRAD@24,400,0,0" />
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<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/css/bootstrap.min.css" rel="stylesheet">
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<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/js/bootstrap.bundle.min.js"></script>
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<style>
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.menu{
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margin : 20px;
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}
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.content{
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padding-left: 250px;
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}
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.nav-link.active {
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background-color: #6FFFE9 !important;
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color: #0B132B !important;
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}
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.nav-link{
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color: #0B132B !important;
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}
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.containerContent a {
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text-decoration: none;
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color: #8296C5;
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}
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.containeritem {
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background-color: #ffffff;
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border-radius: 6px;
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box-shadow: 0 2px 4px rgba(0, 0, 0, 0.1);
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margin-left: 30px;
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padding: 10px;
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display: inline-flex;
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align-items: center;
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width: calc(100% - 120px);
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}
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.tab.active {
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display: block;
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}
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.nav-pills .nav-link {
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cursor: pointer;
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}
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.item {
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padding-left: 265px;
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padding-bottom:50px;
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}
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.nav-item {
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margin-right: 150px;
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}
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.nav-item:last-child {
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margin-right: 0;
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}
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.form-control {
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width: 100%;
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}
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</style>
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<title>Request Consultation</title>
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</head>
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<body>
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<div class="container-flex">
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@include('client-sidebar')
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<div class="item justify-content-center">
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<div class="row">
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<div class="container d-flex justify-content-center" style="padding:50px;">
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<h2>Health Data</h2>
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</div>
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</div>
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<div class="event-form p-5 me-5 ms-5 mt-4">
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<form action="{{ route('health-data.store') }}" method="POST" enctype="multipart/form-data">
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@csrf
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{{-- ROW 1 --}}
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<div class="row">
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{{-- Tanggal Lahir --}}
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<div class="col">
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<div class="mb-3">
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<label for="birthdate" class="form-label">Tanggal Lahir</label>
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<div class="input-group date @error('birthdate') is-invalid @enderror" id="birthdatePicker" data-target-input="nearest">
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<input type="text" class="form-control datetimepicker-input " id="birthdate" name="birthdate" style="border-radius: 20px" data-target="#birthdatePicker" placeholder="Pilih Tanggal Lahir" value="{{ old('birthdate', $healthData->birthdate ?? '') }}"/>
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<div class="input-group-append" data-target="#birthdatePicker" data-toggle="datetimepicker">
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</div>
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</div>
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@error('birthdate')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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{{-- Berat Badan --}}
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<div class="col">
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<div class="mb-3">
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<label for="weight" class="form-label">Berat Badan (kg)</label>
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<input value="{{old('weight', $healthData->weight ?? '')}}" type="text" class="form-control @error('weight') is-invalid @enderror" name="weight" id="weight" aria-describedby="weightHelp" style="border-radius: 20px" placeholder="60" required>
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@error('weight')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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</div>
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{{-- ROW 2 --}}
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<div class="row">
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{{-- Tinggi Badan --}}
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<div class="col">
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<div class="mb-3">
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<label for="height" class="form-label">Tinggi Badan (cm)</label>
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<input value="{{old('height', $healthData->height ?? '')}}" type="text" class="form-control @error('height') is-invalid @enderror" id="height" name="height" aria-describedby="heightHelp" style="border-radius: 20px" placeholder="170">
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@error('height')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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{{-- Waktu Tidur --}}
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<div class="col">
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<div class="mb-3">
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<label for="sleeptime" class="form-label">Waktu Tidur per hari (jam)</label>
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<input value="{{old('sleeptime', $healthData->sleeptime ?? '')}}" type="text" class="form-control @error('sleeptime') is-invalid @enderror" name="sleeptime" id="sleeptime" aria-describedby="sleeptimeHelp" style="border-radius: 20px" placeholder="8">
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@error('sleeptime')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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</div>
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{{-- ROW 3 --}}
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<div class="row">
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{{-- Riwayat Alergi Makanan --}}
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<div class="col">
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<div class="mb-3">
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<label for="disease" class="form-label">Riwayat Alergi Makanan</label>
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<input value="{{old('disease', $healthData->alergi_makanan ?? '')}}" type="text" class="form-control @error('alergi_makanan') is-invalid @enderror" id="alergi_makanan" name="alergi_makanan" aria-describedby="alergi_makananHelp" style="border-radius: 20px" placeholder="Flu">
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@error('alergi_makanan')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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{{-- Kebiasaan Makan --}}
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<div class="col">
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<div class="mb-3">
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<label for="food" class="form-label">Kebiasaan Makan</label>
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<input value="{{old('food', $healthData->food ?? '')}}" type="text" class="form-control @error('food') is-invalid @enderror" name="food" id="food" aria-describedby="foodHelp" style="border-radius: 20px" placeholder="Makanan yang sering dimakan dalam 1 bulan terakhir">
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@error('food')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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</div>
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{{-- ROW 4 --}}
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<div class="row">
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{{-- Riwayat Penyakit --}}
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<div class="col">
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<div class="mb-3">
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<label for="disease" class="form-label">Riwayat Penyakit</label>
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<input value="{{old('disease', $healthData->disease ?? '')}}" type="text" class="form-control @error('disease') is-invalid @enderror" id="disease" name="disease" aria-describedby="diseaseHelp" style="border-radius: 20px" placeholder="Flu">
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@error('disease')
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<div class="invalid-feedback">{{ $message }}</div>
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@enderror
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</div>
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</div>
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</div>
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<div class="row justify-content-end mt-5">
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<div class="col-auto">
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<button class="btn btn-primary" type="submit">Next</button>
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</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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<script src="https://code.jquery.com/jquery-3.7.0.js"></script>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.9.0/js/bootstrap-datepicker.min.js"></script>
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<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/js/bootstrap.bundle.min.js"></script>
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<script>
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$(function () {
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$('#birthdatePicker').datepicker({
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format: 'yyyy-mm-dd',
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autoclose: true,
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todayHighlight: true
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});
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});
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</script>
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</body>
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</html>
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