@extends('layouts.app')

@section('title', 'Nouveau Patient')

@section('content')
<div class="d-flex justify-content-between flex-wrap flex-md-nowrap align-items-center pt-3 pb-2 mb-3 border-bottom">
    <h1 class="h2">
        <i class="fas fa-user-plus me-2"></i>
        Nouveau Patient
    </h1>
    <div class="btn-toolbar mb-2 mb-md-0">
        <a href="{{ route('patients.index') }}" class="btn btn-secondary">
            <i class="fas fa-arrow-left me-1"></i>
            Retour à la liste
        </a>
    </div>
</div>

<div class="card shadow-sm">
    <div class="card-body">
        <form action="{{ route('patients.store') }}" method="POST">
            @csrf
            
            <div class="row">
                <div class="col-md-6">
                    <h5 class="mb-3">Informations personnelles</h5>
                    
                    <div class="mb-3">
                        <label for="first_name" class="form-label">Prénom <span class="text-danger">*</span></label>
                        <input type="text" class="form-control @error('first_name') is-invalid @enderror" 
                               id="first_name" name="first_name" value="{{ old('first_name') }}" required>
                        @error('first_name')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="last_name" class="form-label">Nom <span class="text-danger">*</span></label>
                        <input type="text" class="form-control @error('last_name') is-invalid @enderror" 
                               id="last_name" name="last_name" value="{{ old('last_name') }}" required>
                        @error('last_name')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="date_of_birth" class="form-label">Date de naissance <span class="text-danger">*</span></label>
                        <input type="date" class="form-control @error('date_of_birth') is-invalid @enderror" 
                               id="date_of_birth" name="date_of_birth" value="{{ old('date_of_birth') }}" required>
                        @error('date_of_birth')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="gender" class="form-label">Sexe <span class="text-danger">*</span></label>
                        <select class="form-select @error('gender') is-invalid @enderror" id="gender" name="gender" required>
                            <option value="">Sélectionner...</option>
                            <option value="male" {{ old('gender') == 'male' ? 'selected' : '' }}>Homme</option>
                            <option value="female" {{ old('gender') == 'female' ? 'selected' : '' }}>Femme</option>
                            <option value="other" {{ old('gender') == 'other' ? 'selected' : '' }}>Autre</option>
                        </select>
                        @error('gender')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="phone" class="form-label">Téléphone</label>
                        <input type="tel" class="form-control @error('phone') is-invalid @enderror" 
                               id="phone" name="phone" value="{{ old('phone') }}">
                        @error('phone')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="email" class="form-label">Email</label>
                        <input type="email" class="form-control @error('email') is-invalid @enderror" 
                               id="email" name="email" value="{{ old('email') }}">
                        @error('email')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="address" class="form-label">Adresse</label>
                        <textarea class="form-control @error('address') is-invalid @enderror" 
                                  id="address" name="address" rows="3">{{ old('address') }}</textarea>
                        @error('address')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>
                </div>

                <div class="col-md-6">
                    <h5 class="mb-3">Contact d'urgence</h5>
                    
                    <div class="mb-3">
                        <label for="emergency_contact_name" class="form-label">Nom du contact d'urgence</label>
                        <input type="text" class="form-control @error('emergency_contact_name') is-invalid @enderror" 
                               id="emergency_contact_name" name="emergency_contact_name" value="{{ old('emergency_contact_name') }}">
                        @error('emergency_contact_name')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="emergency_contact_phone" class="form-label">Téléphone du contact d'urgence</label>
                        <input type="tel" class="form-control @error('emergency_contact_phone') is-invalid @enderror" 
                               id="emergency_contact_phone" name="emergency_contact_phone" value="{{ old('emergency_contact_phone') }}">
                        @error('emergency_contact_phone')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <h5 class="mb-3 mt-4">Informations médicales</h5>

                    <div class="mb-3">
                        <label for="medical_history" class="form-label">Antécédents médicaux</label>
                        <textarea class="form-control @error('medical_history') is-invalid @enderror" 
                                  id="medical_history" name="medical_history" rows="4" 
                                  placeholder="Décrire les antécédents médicaux du patient...">{{ old('medical_history') }}</textarea>
                        @error('medical_history')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>

                    <div class="mb-3">
                        <label for="allergies" class="form-label">Allergies</label>
                        <textarea class="form-control @error('allergies') is-invalid @enderror" 
                                  id="allergies" name="allergies" rows="3" 
                                  placeholder="Lister les allergies connues...">{{ old('allergies') }}</textarea>
                        @error('allergies')
                            <div class="invalid-feedback">{{ $message }}</div>
                        @enderror
                    </div>
                </div>
            </div>

            <div class="d-flex justify-content-end gap-2 mt-4">
                <a href="{{ route('patients.index') }}" class="btn btn-secondary">
                    <i class="fas fa-times me-1"></i>
                    Annuler
                </a>
                <button type="submit" class="btn btn-primary">
                    <i class="fas fa-save me-1"></i>
                    Enregistrer
                </button>
            </div>
        </form>
    </div>
</div>
@endsection