{% extends "base.html" %}
{% load static %}

{% block title %}
    {% if object %}Edit Patient - {{ object.get_full_name }}{% else %}Register New Patient{% endif %} - {{ block.super }}
{% endblock %}

{% block content %}
<div class="container-fluid">
    <!-- Page Header -->
    <div class="d-flex justify-content-between align-items-center mb-4">
        <div>
            <h1 class="h3 mb-1">
                <i class="fas fa-user-plus me-2"></i>
                {% if object %}Edit Patient{% else %}Register New Patient{% endif %}
            </h1>
            <nav aria-label="breadcrumb">
                <ol class="breadcrumb mb-0">
                    <li class="breadcrumb-item"><a href="{% url 'core:dashboard' %}">Dashboard</a></li>
                    <li class="breadcrumb-item"><a href="{% url 'patients:patient_list' %}">Patients</a></li>
                    {% if object %}
                        <li class="breadcrumb-item"><a href="{% url 'patients:patient_detail' object.pk %}">{{ object.get_full_name }}</a></li>
                        <li class="breadcrumb-item active">Edit</li>
                    {% else %}
                        <li class="breadcrumb-item active">Register</li>
                    {% endif %}
                </ol>
            </nav>
        </div>
        <div class="btn-group">
            <a href="{% url 'patients:patient_list' %}" class="btn btn-outline-secondary">
                <i class="fas fa-arrow-left me-2"></i>Back to List
            </a>
            {% if object %}
                <a href="{% url 'patients:patient_detail' object.pk %}" class="btn btn-outline-primary">
                    <i class="fas fa-eye me-2"></i>View Patient
                </a>
            {% endif %}
        </div>
    </div>

    <form method="post" enctype="multipart/form-data" id="patientForm" novalidate>
        {% csrf_token %}
        
        <div class="row">
            <!-- Main Form -->
            <div class="col-lg-8">
                <!-- Basic Information -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-user me-2"></i>Basic Information
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.first_name.id_for_label }}" class="form-label">
                                    First Name <span class="text-danger">*</span>
                                </label>
                                {{ form.first_name }}
                                {% if form.first_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.first_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.middle_name.id_for_label }}" class="form-label">Middle Name</label>
                                {{ form.middle_name }}
                                {% if form.middle_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.middle_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.last_name.id_for_label }}" class="form-label">
                                    Last Name <span class="text-danger">*</span>
                                </label>
                                {{ form.last_name }}
                                {% if form.last_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.last_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                        
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.preferred_name.id_for_label }}" class="form-label">Preferred Name</label>
                                {{ form.preferred_name }}
                                {% if form.preferred_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.preferred_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.suffix.id_for_label }}" class="form-label">Suffix</label>
                                {{ form.suffix }}
                                {% if form.suffix.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.suffix.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.mrn.id_for_label }}" class="form-label">
                                    Medical Record Number <span class="text-danger">*</span>
                                </label>
                                {{ form.mrn }}
                                {% if form.mrn.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.mrn.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                    </div>
                </div>

                <!-- Demographics -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-id-card me-2"></i>Demographics
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.date_of_birth.id_for_label }}" class="form-label">
                                    Date of Birth <span class="text-danger">*</span>
                                </label>
                                {{ form.date_of_birth }}
                                {% if form.date_of_birth.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.date_of_birth.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.gender.id_for_label }}" class="form-label">
                                    Gender <span class="text-danger">*</span>
                                </label>
                                {{ form.gender }}
                                {% if form.gender.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.gender.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.sex_assigned_at_birth.id_for_label }}" class="form-label">Sex Assigned at Birth</label>
                                {{ form.sex_assigned_at_birth }}
                                {% if form.sex_assigned_at_birth.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.sex_assigned_at_birth.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                        
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.race.id_for_label }}" class="form-label">Race</label>
                                {{ form.race }}
                                {% if form.race.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.race.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.ethnicity.id_for_label }}" class="form-label">Ethnicity</label>
                                {{ form.ethnicity }}
                                {% if form.ethnicity.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.ethnicity.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.marital_status.id_for_label }}" class="form-label">Marital Status</label>
                                {{ form.marital_status }}
                                {% if form.marital_status.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.marital_status.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                    </div>
                </div>

                <!-- Contact Information -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-phone me-2"></i>Contact Information
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.email.id_for_label }}" class="form-label">Email Address</label>
                                {{ form.email }}
                                {% if form.email.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.email.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-3 mb-3">
                                <label for="{{ form.phone_number.id_for_label }}" class="form-label">Phone Number</label>
                                {{ form.phone_number }}
                                {% if form.phone_number.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.phone_number.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-3 mb-3">
                                <label for="{{ form.mobile_number.id_for_label }}" class="form-label">Mobile Number</label>
                                {{ form.mobile_number }}
                                {% if form.mobile_number.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.mobile_number.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                        
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.address_line_1.id_for_label }}" class="form-label">Address Line 1</label>
                                {{ form.address_line_1 }}
                                {% if form.address_line_1.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.address_line_1.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.address_line_2.id_for_label }}" class="form-label">Address Line 2</label>
                                {{ form.address_line_2 }}
                                {% if form.address_line_2.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.address_line_2.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                        
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.city.id_for_label }}" class="form-label">City</label>
                                {{ form.city }}
                                {% if form.city.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.city.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.state.id_for_label }}" class="form-label">State</label>
                                {{ form.state }}
                                {% if form.state.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.state.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.zip_code.id_for_label }}" class="form-label">ZIP Code</label>
                                {{ form.zip_code }}
                                {% if form.zip_code.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.zip_code.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                    </div>
                </div>

                <!-- Medical Information -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-stethoscope me-2"></i>Medical Information
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.primary_care_physician.id_for_label }}" class="form-label">Primary Care Physician</label>
                                {{ form.primary_care_physician }}
                                {% if form.primary_care_physician.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.primary_care_physician.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.referring_physician.id_for_label }}" class="form-label">Referring Physician</label>
                                {{ form.referring_physician }}
                                {% if form.referring_physician.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.referring_physician.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>
                        
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.allergies.id_for_label }}" class="form-label">Known Allergies</label>
                                {{ form.allergies }}
                                {% if form.allergies.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.allergies.errors.0 }}
                                    </div>
                                {% endif %}
                                <div class="form-text">List any known allergies, medications, or substances</div>
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.medical_alerts.id_for_label }}" class="form-label">Medical Alerts</label>
                                {{ form.medical_alerts }}
                                {% if form.medical_alerts.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.medical_alerts.errors.0 }}
                                    </div>
                                {% endif %}
                                <div class="form-text">Important medical warnings or alerts</div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

            <!-- Sidebar -->
            <div class="col-lg-4">
                <!-- Photo Upload -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-camera me-2"></i>Patient Photo
                        </h5>
                    </div>
                    <div class="card-body text-center">
                        {% if object and object.photo %}
                            <img src="{{ object.photo.url }}" alt="Patient Photo" class="img-fluid rounded-circle mb-3" style="width: 150px; height: 150px; object-fit: cover;">
                        {% else %}
                            <div class="bg-light rounded-circle d-inline-flex align-items-center justify-content-center mb-3" style="width: 150px; height: 150px;">
                                <i class="fas fa-user fa-4x text-muted"></i>
                            </div>
                        {% endif %}
                        
                        <div class="mb-3">
                            {{ form.photo }}
                            {% if form.photo.errors %}
                                <div class="invalid-feedback d-block">
                                    {{ form.photo.errors.0 }}
                                </div>
                            {% endif %}
                        </div>
                        
                        <div class="form-text">
                            Upload a patient photo (optional)<br>
                            Recommended: 300x300px, JPG/PNG format
                        </div>
                    </div>
                </div>

                <!-- Language & Communication -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-language me-2"></i>Language & Communication
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="mb-3">
                            <label for="{{ form.primary_language.id_for_label }}" class="form-label">Primary Language</label>
                            {{ form.primary_language }}
                            {% if form.primary_language.errors %}
                                <div class="invalid-feedback d-block">
                                    {{ form.primary_language.errors.0 }}
                                </div>
                            {% endif %}
                        </div>
                        
                        <div class="mb-3">
                            <label for="{{ form.communication_preference.id_for_label }}" class="form-label">Communication Preference</label>
                            {{ form.communication_preference }}
                            {% if form.communication_preference.errors %}
                                <div class="invalid-feedback d-block">
                                    {{ form.communication_preference.errors.0 }}
                                </div>
                            {% endif %}
                        </div>
                        
                        <div class="form-check">
                            {{ form.interpreter_needed }}
                            <label class="form-check-label" for="{{ form.interpreter_needed.id_for_label }}">
                                Interpreter services needed
                            </label>
                        </div>
                    </div>
                </div>

                <!-- Special Flags -->
                <div class="card mb-4">
                    <div class="card-header">
                        <h5 class="mb-0">
                            <i class="fas fa-flag me-2"></i>Special Flags
                        </h5>
                    </div>
                    <div class="card-body">
                        <div class="form-check mb-2">
                            {{ form.is_vip }}
                            <label class="form-check-label" for="{{ form.is_vip.id_for_label }}">
                                VIP Patient
                            </label>
                        </div>
                        
                        <div class="form-check mb-2">
                            {{ form.confidential_patient }}
                            <label class="form-check-label" for="{{ form.confidential_patient.id_for_label }}">
                                Confidential Patient
                            </label>
                        </div>
                        
                        <div class="form-check mb-2">
                            {{ form.has_advance_directive }}
                            <label class="form-check-label" for="{{ form.has_advance_directive.id_for_label }}">
                                Has Advance Directive
                            </label>
                        </div>
                        
                        {% if form.advance_directive_type %}
                        <div class="mb-3" id="advanceDirectiveType" style="display: none;">
                            <label for="{{ form.advance_directive_type.id_for_label }}" class="form-label">Advance Directive Type</label>
                            {{ form.advance_directive_type }}
                        </div>
                        {% endif %}
                    </div>
                </div>

                <!-- Form Actions -->
                <div class="card">
                    <div class="card-body">
                        <div class="d-grid gap-2">
                            <button type="submit" class="btn btn-primary">
                                <i class="fas fa-save me-2"></i>
                                {% if object %}Update Patient{% else %}Register Patient{% endif %}
                            </button>
                            
                            <button type="button" class="btn btn-outline-secondary" onclick="resetForm()">
                                <i class="fas fa-undo me-2"></i>Reset Form
                            </button>
                            
                            <a href="{% url 'patients:patient_list' %}" class="btn btn-outline-danger">
                                <i class="fas fa-times me-2"></i>Cancel
                            </a>
                        </div>
                        
                        {% if object %}
                        <hr>
                        <div class="text-center">
                            <small class="text-muted">
                                Created: {{ object.created_at|date:"M d, Y H:i" }}<br>
                                Last Updated: {{ object.updated_at|date:"M d, Y H:i" }}
                            </small>
                        </div>
                        {% endif %}
                    </div>
                </div>
            </div>
        </div>
    </form>
</div>

<script>
// Form validation and interactions
document.addEventListener('DOMContentLoaded', function() {
    // Show/hide advance directive type based on checkbox
    const hasAdvanceDirective = document.getElementById('{{ form.has_advance_directive.id_for_label }}');
    const advanceDirectiveType = document.getElementById('advanceDirectiveType');
    
    if (hasAdvanceDirective && advanceDirectiveType) {
        function toggleAdvanceDirectiveType() {
            if (hasAdvanceDirective.checked) {
                advanceDirectiveType.style.display = 'block';
            } else {
                advanceDirectiveType.style.display = 'none';
            }
        }
        
        hasAdvanceDirective.addEventListener('change', toggleAdvanceDirectiveType);
        toggleAdvanceDirectiveType(); // Initial state
    }
    
    // Form validation
    const form = document.getElementById('patientForm');
    form.addEventListener('submit', function(event) {
        if (!form.checkValidity()) {
            event.preventDefault();
            event.stopPropagation();
        }
        form.classList.add('was-validated');
    });
    
    // Auto-format phone numbers
    const phoneInputs = document.querySelectorAll('input[type="tel"]');
    phoneInputs.forEach(function(input) {
        input.addEventListener('input', function(e) {
            let value = e.target.value.replace(/\D/g, '');
            if (value.length >= 6) {
                value = value.replace(/(\d{3})(\d{3})(\d{4})/, '($1) $2-$3');
            } else if (value.length >= 3) {
                value = value.replace(/(\d{3})(\d{3})/, '($1) $2');
            }
            e.target.value = value;
        });
    });
    
    // Auto-format SSN
    const ssnInput = document.querySelector('input[name="ssn"]');
    if (ssnInput) {
        ssnInput.addEventListener('input', function(e) {
            let value = e.target.value.replace(/\D/g, '');
            if (value.length >= 5) {
                value = value.replace(/(\d{3})(\d{2})(\d{4})/, '$1-$2-$3');
            } else if (value.length >= 3) {
                value = value.replace(/(\d{3})(\d{2})/, '$1-$2');
            }
            e.target.value = value;
        });
    }
});

// Reset form function
function resetForm() {
    if (confirm('Are you sure you want to reset the form? All unsaved changes will be lost.')) {
        document.getElementById('patientForm').reset();
        document.getElementById('patientForm').classList.remove('was-validated');
    }
}

// Auto-save functionality (optional)
let autoSaveTimer;
function autoSave() {
    clearTimeout(autoSaveTimer);
    autoSaveTimer = setTimeout(function() {
        // Implement auto-save logic here if needed
        console.log('Auto-saving form...');
    }, 30000); // Auto-save every 30 seconds
}

// Trigger auto-save on form changes
document.getElementById('patientForm').addEventListener('input', autoSave);
</script>

<style>
.form-control, .form-select {
    border-radius: 0.375rem;
    border: 1px solid #ced4da;
    transition: border-color 0.15s ease-in-out, box-shadow 0.15s ease-in-out;
}

.form-control:focus, .form-select:focus {
    border-color: #86b7fe;
    outline: 0;
    box-shadow: 0 0 0 0.25rem rgba(13, 110, 253, 0.25);
}

.card {
    box-shadow: 0 0.125rem 0.25rem rgba(0, 0, 0, 0.075);
    border: 1px solid rgba(0, 0, 0, 0.125);
}

.card-header {
    background-color: rgba(13, 110, 253, 0.1);
    border-bottom: 1px solid rgba(0, 0, 0, 0.125);
}

.btn {
    border-radius: 0.375rem;
    transition: all 0.15s ease-in-out;
}

.btn:hover {
    transform: translateY(-1px);
    box-shadow: 0 4px 8px rgba(0, 0, 0, 0.1);
}

.invalid-feedback {
    font-size: 0.875rem;
}

.form-text {
    font-size: 0.875rem;
    color: #6c757d;
}

@media (max-width: 768px) {
    .btn-group {
        display: flex;
        flex-direction: column;
        gap: 0.5rem;
    }
}
</style>
{% endblock %}