<?php echo form_open('checkup/submit'); ?>
	<fieldset>
		<legend>Informasi Data Dokter</legend>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Dokter ID</label>
			<div class="col-sm-10">
				<input type="text" class="form-control" readonly>
			</div>
		</div>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Nama Dokter</label>
			<div class="col-sm-10">
				<input type="text" class="form-control" readonly>
			</div>
		</div>

	</fieldset>

	<fieldset>
		<legend>Informasi Data Pasien</legend>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Pasien Id</label>
			<div class="col-sm-10">
				<div class="input-group">
					<input type="text" class="form-control">
				  <div class="input-group-append">
					<button class="btn btn-outline-secondary" type="button" data-toggle="modal" data-target="#pasienModal">Browse</button>
				  </div>
				</div>
			</div>
		</div>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Nama Pasien</label>
			<div class="col-sm-10">
				<input type="text" readonly class="form-control">
			</div>
		</div>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Alamat</label>
			<div class="col-sm-10">
				<input type="text" readonly class="form-control">
			</div>
		</div>
	</fieldset>

	<fieldset>
		<legend>Information Checkup</legend>
		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Tgl Checkup</label>
			<div class="col-sm-10">
				<input type="date"  class="form-control">
			</div>
		</div>


		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Keluhan</label>
			<div class="col-sm-10">
				<textarea  class="form-control"></textarea>
			</div>
		</div>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Diagnosa</label>
			<div class="col-sm-10">
				<textarea  class="form-control"></textarea>
			</div>
		</div>

		<div class="form-group row">
			<label  class="col-sm-2 col-form-label">Obat</label>
			<div class="col-sm-10">
				<div style="float:right;padding:10px;">
					<button type="button" class="btn btn-primary" data-toggle="modal" data-target="#obatModal">Add Item</button>
					<button type="button" class="btn btn-secondary">Submit Data</button>
				</div>

				<table class="table">
				  <thead>
					<tr>
					  <th scope="col">#</th>
					  <th scope="col">ID OBAT</th>
					  <th scope="col">NAMA OBAT</th>
					  <th scope="col">QTY</th>
					  <th scope="col">SATUAN</th>
					  <th scope="col">TOTAL</th>
					</tr>
				  </thead>
				  <tbody>
						<tr>
							<th scope="row">
								<button type="button" class="btn btn-danger">Delete</button>
							</th>
							<td>Mark</td>
							<td>Mark</td>
							<td>Mark</td>
							<td>Mark</td>
							<td>Mark</td>
						</tr>
					</tbody>
				</table>
			</div>
		</div>
	</fieldset>

<?php echo form_close(); ?>



<!-- Modal -->
<div class="modal fade" id="pasienModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
  <div class="modal-dialog" role="document">
    <div class="modal-content">
      <div class="modal-header">
        <h5 class="modal-title" id="exampleModalLabel">Dialog Pencarian Pasien</h5>
        <button type="button" class="close" data-dismiss="modal" aria-label="Close">
          <span aria-hidden="true">&times;</span>
        </button>
      </div>
      <div class="modal-body">
        ...
      </div>
      <div class="modal-footer">
        <button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
      </div>
    </div>
  </div>
</div>

<!-- Modal -->
<div class="modal fade" id="obatModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
  <div class="modal-dialog" role="document">
    <div class="modal-content">
      <div class="modal-header">
        <h5 class="modal-title" id="exampleModalLabel">Dialog Pencarian Obat</h5>
        <button type="button" class="close" data-dismiss="modal" aria-label="Close">
          <span aria-hidden="true">&times;</span>
        </button>
      </div>
      <div class="modal-body">
        ...
      </div>
      <div class="modal-footer">
        <button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
      </div>
    </div>
  </div>
</div>