<!-- First, extends to the CRUDBooster Layout -->
<?php
setlocale(LC_ALL, 'IND');
?>

@extends('crudbooster::admin_template')
@section('content')
  <!-- Your html goes here -->

    <?php //var_dump($row); ?>

        <div class='panel panel-default'>
            <div class='panel-heading'>{{ $jenis_surat->nama_surat }}</div>
        
                <div class='panel-body'>
                    <div >
        			  <label>NIK</label>
        			  <p>{{ $warga->nik }}</p>
        			</div>
        			<div >
        			  <label>Nama Pemilik</label>
        			  <p>{{ $warga->nama_lgkp }}</p>
        			</div>
        			<div >
        			  <label>Alamat Pemilik</label>
        			  <p>{{ $warga->alamat }}</p>
        			</div>
        			
                    <div >
        			  <label>Macam Hewan</label>
        			  <p>{{ $row->macam_hewan }}</p>
        			</div>
        			<div >
        			  <label>Nama Hewan</label>
        			  <p>{{ $row->nama_hewan  }}</p>
        			</div>
        			<div >
        			  <label>Signalemen</label>
        			  <p>{{ $row->signalemen  }}</p>
        			</div>
        			<div >
        			  <label>Penyakit</label>
        			  <p>{{ $row->penyakit  }}</p>
        			</div>

                
                <form class="form-horizontal" method='post' action='{{CRUDBooster::mainpath("cetak-surat-dua/".$id)}}'>
    		        <input type="hidden" name="_token" value="{{ csrf_token() }}"/>
    		        <input type="hidden" name="id" value="{{ $id }}"/>
    		        <input type="hidden" name="rel_table" value="{{ $rel_table }}"/>
    		        <input type="hidden" name="rel_id" value="{{ $rel_id }}"/>
    		        <input type="hidden" name="jenis_surat_id" value="{{ $jenis_surat->id }}"/>
    		        
    		        
    		        
                    
                        <div class="panel panel-default">
                            <div class="panel-heading"><strong>ANAMNESA</strong></div>
                            <div class="panel-heading"><strong>STATUS PRESENS</strong></div>
                            <div class="panel-body">
                                <div class="box-body">
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Keadaan Umum<span class="text-danger" title="Tidak boleh kosong">*</span>
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Keadaan umum"  maxlength="255" class="form-control" name="keadaan_umum" id="keadaan_umum" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Frek. nafas
                                        </label>
                                        <div class="col-sm-2">
                                            <input type="text" title="Frek. nafas"  maxlength="255" class="form-control" name="frek_nafas" id="frek_nafas" value="">
                                        </div>
                                        <div class="col-sm-1">
                                            <p>/menit</p>
                                        </div>
                                    </div>
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Frek. Pulsus
                                        </label>
                                        <div class="col-sm-2">
                                            <input type="text" title="Frek. Pulsus"  maxlength="255" class="form-control" name="frek_pulsus" id="frek_pulsus" value="">
                                        </div>
                                        <div class="col-sm-1">
                                            <p>/menit</p>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Suhu tubuh
                                        </label>
                                        <div class="col-sm-2">
                                            <input type="text" title="Suhu tubuh"  maxlength="255" class="form-control" name="suhu_tubuh" id="suhu_tubuh" value="">
                                        </div>
                                        <div class="col-sm-1">
                                            <p>/ C</p>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Kulit dan Rambut
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Kulit dan Rambut"  maxlength="255" class="form-control" name="kulit_dan_rambut" id="kulit_dan_rambut" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Selaput Lendir
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Selaput Lendir"  maxlength="255" class="form-control" name="selaput_lendir" id="selaput_lendir" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Kelenjar Limfe
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Kelenjar Limfe"  maxlength="255" class="form-control" name="kelenjar_limfe" id="kelenjar_limfe" value="">
                                        </div>
                                    </div>
                                    
                                     <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Susunan Alat Penafasan
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Susunan Alat Penafasan"  maxlength="255" class="form-control" name="susunan_alat_pernafasan" id="susunan_alat_pernafasan" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Susunan Alat Peredaran Darah
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Susunan Alat Peredaran Darah"  maxlength="255" class="form-control" name="susunan_alat_peredaran_darah" id="susunan_alat_peredaran_darah" value="">
                                        </div>
                                    </div>
                                    
                                     <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Susunan Alat Kelamin dan Perkemihan
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Susunan Alat Kelamin dan Perkemihan"  maxlength="255" class="form-control" name="susunan_alat_kelamin_dan_perkeminan" id="susunan_alat_kelamin_dan_perkeminan" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Susunan Urat Saraf
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Susunan Urat Saraf"  maxlength="255" class="form-control" name="susunan_urat_saraf" id="susunan_urat_saraf" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Anggota Gerak
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Anggota Gerak"  maxlength="255" class="form-control" name="anggota_gerak" id="anggota_gerak" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Berat Badan
                                        </label>
                                        <div class="col-sm-2">
                                            <input type="text" title="Berat Badan"  maxlength="255" class="form-control" name="berat_badan" id="berat_badan" value="">
                                        </div>
                                        <div class="col-sm-1">
                                            <p> Kg</p>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Lain-lain
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Lain-lain"  maxlength="255" class="form-control" name="lain_lain" id="lain_lain" value="">
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="panel panel-default">
                            <div class="panel-heading"><strong>Pemeriksaan Laboratorium</strong></div>
                            <div class="panel-body">
                                <div class="box-body">
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Feses
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Feses"  maxlength="255" class="form-control" name="lab_feses" id="lab_feses" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Konsistensi
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Konsistensi"  maxlength="255" class="form-control" name="lab_konsistensi" id="lab_konsistensi" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Centrifuge
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Centrifuge"  maxlength="255" class="form-control" name="lab_centrifuge" id="lab_centrifuge" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Lain-lain
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Lain-lain"  maxlength="255" class="form-control" name="lab_lain_lain" id="lab_lain_lain" value="">
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="panel panel-default">
                            <div class="panel-heading"><strong>DIAGNOSA</strong></div>
                            <div class="panel-body">
                                <div class="box-body">
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Urine
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Urine"  maxlength="255" class="form-control" name="diag_urine" id="diag_urine" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Reaksi
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Reaksi"  maxlength="255" class="form-control" name="diag_reaksi" id="diag_reaksi" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Protein
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Protein"  maxlength="255" class="form-control" name="diag_protein" id="diag_protein" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Sediment
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Sediment"  maxlength="255" class="form-control" name="diag_sedimen" id="diag_sedimen" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Lain-lain
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Lain-lain"  maxlength="255" class="form-control" name="diag_lain_lain" id="diag_lain_lain" value="">
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="panel panel-default">
                            <div class="panel-heading"><strong>PROGNOSA</strong></div>
                            <div class="panel-body">
                                <div class="box-body">
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Darah
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Darah"  maxlength="255" class="form-control" name="prog_darah" id="prog_darah" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Sifat
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Sifat"  maxlength="255" class="form-control" name="prog_sifat" id="prog_sifat" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Protein
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Protein"  maxlength="255" class="form-control" name="prog_protein" id="prog_protein" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Kadar HB
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Kadar HB"  maxlength="255" class="form-control" name="prog_kadar_hb" id="prog_kadar_hb" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Pr. Apus
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Pr. Apus"  maxlength="255" class="form-control" name="prog_pr_apus" id="prog_pr_apus" value="">
                                        </div>
                                    </div>
                                    
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <label class="control-label col-sm-2">
                                            Lain-lain
                                        </label>
                                        <div class="col-sm-5">
                                            <input type="text" title="Lain-lain"  maxlength="255" class="form-control" name="prog_lain_lain" id="prog_lain_lain" value="">
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="panel panel-default">
                            <div class="panel-heading"><strong>TERAPI</strong></div>
                            <div class="panel-body">
                                <div class="box-body">
                                    <div class="form-group header-group-0 " id="form-group-kod" style="">
                                        <div class="col-sm-9">
                                            <textarea  title="Terapi"  maxlength="255" class="form-control" name="terapi" id="terapi" value=""></textarea>
                                        </div>
                                    </div>
                                    
                                    
                                </div>
                            </div>
                        </div>
                        
        		        <div class="form-group header-group-0 " id="form-group" style="">
                            <label class="control-label col-sm-2">
                                Nomor Surat<span class="text-danger" title="Tidak boleh kosong">*</span>
                            </label>
                            <div class="col-sm-5">
                                <input type="text" title="Nomor surat" required="" maxlength="50" class="form-control" name="nomor" id="nomor" value="">
                            </div>
                        </div>
                        
                        <div class="form-group header-group-0">
            			  <label class="control-label col-sm-2">Tanggal Surat *</label>
            			  <div class="col-sm-5">
            			    <input class="form-control" type="date" name="tanggal" />
            			  </div>
            			</div>
        			
            			<div class="form-group header-group-0">
                          <label class="control-label col-sm-2">Penandatangan *</label>
                          <div class="col-sm-5">
                              <select name="penandatangan"  class="form-control">
                                  <option value="">**Pilih Pejabat/Penandatangan</option>
                                    @foreach($pejabat as $pjb)
                                        <option  value="{{ $pjb->id }}">{{ $pjb->nama_pejabat . ' - NIP. ' . $pjb->nip_pejabat . ' - ' . $pjb->jabatan }}</option>
                                    @endforeach
                              </select>
                            </div>
                        </div>
                    

        			
    		        
        			<div class='form-group'>
        			    <!--<input type="submit" class='btn btn-primary' value="VERIFIKASI" style="margin-left:15px"/>-->
    					<input type="submit" class='btn btn-primary' value="CETAK" style="margin-left:15px"/>
    					<input type="button" class='btn btn-primary' value="KEMBALI" onclick="window.location.href='{{ CRUDBooster::adminPath('surat_masuk') }}'" style="margin-left:15px"/>
    				</div>
    			</form>
    			
    			</div>
            <div class='panel-footer'>
              
            </div>
      </div>

		

@endsection