@php
    $departments = ['General OPD','Cataract','Dialysis','Other'];
@endphp

<div class="row">
  <div class="col-md-6">
    <div class="mb-3">
      <label class="form-label">Patient Name</label>
      <input name="name" value="{{ old('name', $patient->name ?? '') }}" class="form-control" required>
    </div>
  </div>
  <div class="col-md-2">
    <div class="mb-3">
      <label class="form-label">Age</label>
      <input name="age" value="{{ old('age', $patient->age ?? '') }}" class="form-control" type="number">
    </div>
  </div>
  <div class="col-md-2">
    <div class="mb-3">
      <label class="form-label">Weight (kg)</label>
      <input name="weight" value="{{ old('weight', $patient->weight ?? '') }}" class="form-control">
    </div>
  </div>
  <div class="col-md-2">
    <div class="mb-3">
      <label class="form-label">Height (cm)</label>
      <input name="height" value="{{ old('height', $patient->height ?? '') }}" class="form-control">
    </div>
  </div>
</div>

<div class="row">
  <div class="col-md-3">
    <div class="mb-3">
      <label class="form-label">Gender</label>
      <select name="gender" class="form-control">
        <option value="">--</option>
        <option value="male" {{ (old('gender', $patient->gender ?? '')=='male')?'selected':'' }}>Male</option>
        <option value="female" {{ (old('gender', $patient->gender ?? '')=='female')?'selected':'' }}>Female</option>
        <option value="other" {{ (old('gender', $patient->gender ?? '')=='other')?'selected':'' }}>Other</option>
      </select>
    </div>
  </div>
  <div class="col-md-3">
    <div class="mb-3">
      <label class="form-label">CNIC</label>
      <input name="cnic" value="{{ old('cnic', $patient->cnic ?? '') }}" class="form-control">
    </div>
  </div>
  <div class="col-md-3">
    <div class="mb-3">
      <label class="form-label">Contact</label>
      <input name="contact" value="{{ old('contact', $patient->contact ?? '') }}" class="form-control">
    </div>
  </div>
  <div class="col-md-3">
    <div class="mb-3">
      <label class="form-label">Department</label>
      <select name="department" class="form-control">
        @foreach($departments as $d)
          <option value="{{ $d }}" {{ (old('department', $patient->department ?? '')==$d)?'selected':'' }}>{{ $d }}</option>
        @endforeach
      </select>
    </div>
  </div>
</div>

<hr>
<h5>Medical History & Vitals</h5>
<div class="mb-3">
  <label class="form-label">Surgical History</label>
  <textarea name="surgical_history" class="form-control" rows="2">{{ old('surgical_history', $patient->surgical_history ?? '') }}</textarea>
</div>
<div class="mb-3">
  <label class="form-label">Allergies / Ongoing Medications</label>
  <textarea name="allergies_medications" class="form-control" rows="2">{{ old('allergies_medications', $patient->allergies_medications ?? '') }}</textarea>
</div>

<div class="row">
  <div class="col-md-2"><input name="bp" value="{{ old('bp', $patient->bp ?? '') }}" class="form-control" placeholder="BP"></div>
  <div class="col-md-2"><input name="pulse" value="{{ old('pulse', $patient->pulse ?? '') }}" class="form-control" placeholder="Pulse"></div>
  <div class="col-md-2"><input name="temperature" value="{{ old('temperature', $patient->temperature ?? '') }}" class="form-control" placeholder="Temp"></div>
  <div class="col-md-2"><input name="ecg" value="{{ old('ecg', $patient->ecg ?? '') }}" class="form-control" placeholder="ECG"></div>
  <div class="col-md-4"><input name="blood_sugar" value="{{ old('blood_sugar', $patient->blood_sugar ?? '') }}" class="form-control" placeholder="Blood sugar"></div>
</div>

<div class="mb-3 mt-3">
  <label class="form-label">Treatment Plan</label>
  <textarea name="treatment_plan" class="form-control" rows="3">{{ old('treatment_plan', $patient->treatment_plan ?? '') }}</textarea>
</div>