@extends('base')

@section('content')
    <form action="{{ route('students.store') }}" method="POST" class="custom-validation" novalidate="">
        @csrf

        <h4 class="card-title mb-4">Información General Estudiante</h4>
        <div class="row">
            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Nombres Completos</label>
                    <div>
                        <input type="text" class="form-control" id="name_student" name="name_student" required
                            placeholder="Digite Nombres Completos" value="{{ old('name_student') }}">
                    </div>
                </div>

                @error('name_student')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Apellidos</label>
                    <div>
                        <input type="text" class="form-control" id="lastName_student" name="lastName_student" required
                            placeholder="Digite Apellidos" value="{{ old('lastName_student') }}">
                    </div>
                </div>

                @error('lastName_student')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-2">
                <div class="mb-3">
                    <label for="">Tipo de Documento</label>
                    <div>
                        <select class="form-select" aria-label="Default select example" id="type_document"
                            name="type_document">
                            <option value=""> -Seleccione Tipo Documento- </option>
                            <option value='Registro Civil' @if (old('type_document') == "Registro Civil") {{ 'selected' }} @endif>Registro Civil</option>
                            <option value='Tarjeta de Identidad' @if (old('type_document') == "Tarjeta de Identidad") {{ 'selected' }} @endif>Tarjeta de Identidad</option>
                            <option value='Cedula de Ciudadania' @if (old('type_document') == "Cedula de Ciudadania") {{ 'selected' }} @endif>Cedula de Ciudadanía</option>
                            <option value='Cedula de Extranjería' @if (old('type_document') == "Cedula de Extranjería") {{ 'selected' }} @endif>Cedula de Extranjería</option>
                            <option value='Pasaporte'@if (old('type_document') == "Pasaporte") {{ 'selected' }} @endif>Pasaporte</option>
                        </select>
                    </div>
                </div>

                @error('type_document')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-2">
                <div class="mb-3">
                    <label for="">N° Documento</label>
                    <div>
                        <input type="text" class="form-control" id="number_document" name="number_document" required
                            placeholder="Digite Número de Documento" value="{{ old('number_document') }}">
                    </div>
                </div>

                @error('number_document')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-2">
                <div class="mb-3">
                    <label for="">Fecha Expedición Documento</label>
                    <div>
                        <input type="date" class="form-control" id="date_expedition" name="date_expedition" required
                            value="{{ old('date_expedition') }}">
                    </div>
                </div>

                @error('date_expedition')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>
        </div>

        <div class="row">
            <div class="col-md-4">
                <div class="mb-3">
                    <label for="">Lugar de Nacimiento</label>
                    <select class="form-select select2" aria-label="Default select example" id="city_id" name="city_id">
                        <option value="" selected> --Seleccione Ciudad -- </option>
                        @foreach ($cities as $city)
                        <option value={{ $city->id}} @if (old('city_id') == $city->id) {{ 'selected' }} @endif>{{ $city->name_city}}</option>
                        @endforeach
                    </select>
                </div>

                @error('city_id')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Fecha de Nacimiento</label>
                    <div>
                        <input type="date" class="form-control" id="date_birth" name="date_birth" required
                            value="{{ old('date_birth') }}">
                    </div>
                </div>

                @error('date_birth')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-2">
                <div class="mb-3">
                    <label for="">Género</label>
                    <div>
                        <select class="form-select" aria-label="Default select example" id="gender"
                            name="gender" value="{{ old('gender') }}">
                            <option value=""> -Seleccione Género- </option>
                            <option value='Masculino' @if (old('gender') == "Masculino") {{ 'selected' }} @endif>Masculino</option>
                            <option value='Femenino' @if (old('gender') == "Femenino") {{ 'selected' }} @endif>Femenino</option>
                        </select>
                    </div>
                </div>

                @error('gender')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>


            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Telefonos</label>
                    <div>
                        <input type="text" class="form-control" id="telephone" name="telephone" required
                            placeholder="Digite Teléfono de contacto" value="{{ old('telephone') }}">
                    </div>
                </div>

                @error('telephone')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>
        </div>

        <div class="row">
            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Direccion de Residencia</label>
                    <div>
                        <input type="text" class="form-control" id="residence_address" name="residence_address" required
                            placeholder="Digite Direccion de Residencia" value="{{ old('residence_address') }}">
                    </div>
                </div>

                @error('residence_address')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Barrio</label>
                    <div>
                        <input type="text" class="form-control" id="neighborhood" name="neighborhood" required
                            placeholder="Digite Direccion de Residencia" value="{{ old('neighborhood') }}">
                    </div>
                </div>

                @error('neighborhood')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Institución de Origen</label>
                    <div>
                        <input type="text" class="form-control" id="origin_institution" name="origin_institution" required
                            placeholder="Digite Instituticion de origen" value="{{ old('origin_institution') }}">
                    </div>
                </div>

                @error('origin_institution')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-3">
                <div class="mb-3">
                    <label for="">Ultimo Grado Cursado</label>
                    <div>
                        <input type="text" class="form-control" id="last_grade" name="last_grade" required
                            placeholder="Digite Ultimo grado Cursado" value="{{ old('last_grade') }}">
                    </div>
                </div>

                @error('last_grade')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>
        </div>

        <h4 class="card-title mb-4 mt-4">Información General Salud</h4>

        <div class="row">
            <div class="col-md-4">
                <div class="mb-3">
                    <label for="">EPS</label>
                    <select class="form-select select2" aria-label="Default select example" id="eps_id" name="eps_id">
                        <option value=""> --Seleccione EPS -- </option>
                        @foreach ($eps as $item)
                        <option value={{ $item->id}}  @if (old('eps_id') == $item->id) {{ 'selected' }} @endif>{{ $item->name_eps}}</option>
                        @endforeach
                    </select>
                </div>

                @error('eps')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>


            <div class="col-md-4">
                <div class="mb-3">
                    <label for="">Grupo Sanguineo</label>
                    <select class="form-select" aria-label="Default select example" id="blood_type" name="blood_type">
                        <option value=""> --Seleccione RH -- </option>
                            <option value="O-" @if (old('blood_type') == "0-") {{ 'selected' }} @endif>O-</option>
                            <option value="O+" @if (old('blood_type') == "0+") {{ 'selected' }} @endif>O+</option>
                            <option value="A+" @if (old('blood_type') == "A+") {{ 'selected' }} @endif>A+</option>
                            <option value="A-" @if (old('blood_type') == "A-") {{ 'selected' }} @endif>A-</option>
                            <option value="B+" @if (old('blood_type') == "B+") {{ 'selected' }} @endif>B+</option>
                            <option value="B-" @if (old('blood_type') == "B-") {{ 'selected' }} @endif>B-</option>
                            <option value="AB+" @if (old('blood_type') == "AB+") {{ 'selected' }} @endif>AB+</option>
                            <option value="AB-" @if (old('blood_type') == "AB-") {{ 'selected' }} @endif>AB-</option>
                    </select>
                </div>

                @error('blood_type')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>

            <div class="col-md-4">
                <div class="mb-3">
                    <label for="">Alergias</label>
                    <div>
                        <input type="text" class="form-control" id="allergies" name="allergies" required
                            placeholder="Digite N/A si no Aplica" value="{{ old('allergies') }}">
                    </div>
                </div>

                @error('allergies')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>
        </div>

        <div class="row">
            <div class="col-md-12">
                <div class="mb-3">
                    <label for="">Información General de Salud</label>
                    <div>
                        <textarea required="" class="form-control" rows="5" id="information_health"
                            name="information_health" placeholder="Digite Datos relevantes de Salud" required></textarea>

                    </div>
                </div>

                @error('information_health')
                    <div class="alert alert-danger alert-dismissible fade show" role="alert">
                        <i class="mdi mdi-block-helper me-2"></i>
                        {{ $message }}
                        <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                    </div>
                @enderror
            </div>
        </div>

        <div class="row">
            <div class="col-md-4">
                <div class="mb-3">
                    <label for="status">Estado del Estudiante</label>
                    <select class="form-select" aria-label="Default select example" id="status_student" name="status_student">
                        <option value="">-Seleccione una opción-</option>
                        <option value="1">Activo</option>
                        <option value="0">Inactivo</option>

                    </select>
                </div>

                @error('status')
                <div class="alert alert-danger alert-dismissible fade show" role="alert">
                    <i class="mdi mdi-block-helper me-2"></i>
                    {{ $message }}
                    <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button>
                </div>
                @enderror
            </div>
        </div>
        <div class="mb-0 float-end">
            <div>
                <button type="submit" class="btn btn-primary waves-effect waves-light me-1">
                    Guardar Registro
                </button>
            </div>
        </div>
    </form>
@endsection