old/form.html

{% extends "base.html" %}
{% block content %}
<h2>Patient Discharge Form</h2>
<form method="POST">
    <!-- Patient Details -->
    <h3>Patient Details</h3>
    <input type="text" name="first_name" placeholder="First Name" required>
    <input type="text" name="last_name" placeholder="Last Name" required>
    <input type="text" name="middle_initial" placeholder="Middle Initial"><br>
    <input type="text" name="dob" placeholder="Date of Birth" required>
    <input type="text" name="age" placeholder="Age" required>
    <input type="text" name="sex" placeholder="Sex" required><br>
    <input type="text" name="address" placeholder="Address" required><br>
    <input type="text" name="city" placeholder="City" required>
    <input type="text" name="state" placeholder="State" required>
    <input type="text" name="zip_code" placeholder="Zip Code" required><br>
    <!-- Doctor Details -->
    <h3>Primary Healthcare Professional Details</h3>
    <input type="text" name="doctor_first_name" placeholder="Doctor's First Name" required>
    <input type="text" name="doctor_last_name" placeholder="Doctor's Last Name" required>
    <input type="text" name="doctor_middle_initial" placeholder="Doctor's Middle Initial"><br>
    <input type="text" name="hospital_name" placeholder="Hospital/Clinic Name" required><br>
    <input type="text" name="doctor_address" placeholder="Doctor Address" required><br>
    <input type="text" name="doctor_city" placeholder="Doctor City" required>
    <input type="text" name="doctor_state" placeholder="Doctor State" required>
    <input type="text" name="doctor_zip" placeholder="Doctor Zip Code" required><br>
    <!-- Admission/Discharge Details -->
    <h3>Admission and Discharge Details</h3>
    <input type="text" name="admission_date" placeholder="Admission Date" required>
    <input type="text" name="referral_source" placeholder="Referral Source" required><br>
    <input type="text" name="admission_method" placeholder="Admission Method" required><br>
    <input type="text" name="discharge_date" placeholder="Discharge Date" required>
    <select name="discharge_reason" required>
        <option value="Treated">Treated</option>
        <option value="Transferred">Transferred</option>
        <option value="Discharge Against Advice">Discharge Against Advice</option>
        <option value="Patient Died">Patient Died</option>
    </select><br>
    <input type="text" name="date_of_death" placeholder="Date of Death (if applicable)"><br>
    <!-- Diagnosis & Procedures -->
    <h3>Diagnosis & Procedures</h3>
    <textarea name="diagnosis" placeholder="Diagnosis" required></textarea><br>
    <textarea name="procedures" placeholder="Procedures" required></textarea><br>
    <!-- Medications -->
    <h3>Medication Details</h3>
    <textarea name="medications" placeholder="Medications on Discharge" required></textarea><br>
    <!-- Preparer -->
    <h3>Prepared By</h3>
    <input type="text" name="preparer_name" placeholder="Preparer Name" required>
    <input type="text" name="preparer_job_title" placeholder="Job Title" required><br>
    <input type="submit" name="display" value="Display Form" class="cyberpunk-button">
    <input type="submit" name="generate_pdf" value="Generate PDF (No AI)" class="cyberpunk-button">
</form>
{% if form_output %}
<div>{{ form_output | safe }}</div>
{% endif %}
{% endblock %}