sidebar end-->
<!--main content start-->
<style type="text/css">
.required:after {
content:"*";
color:red;
}
</style>
<div class="content-body">
    <section id="main-content">
        <section class="wrapper site-min-height">
            <!-- page start-->
            <section class="row col-md-12">
                <!-- <header class="panel-heading">
                    <?php
                    if (!empty($nurse->id))
                    echo lang('Edit Patient');
                    else
                    echo lang('New Assessment');
                    ?>
                </header> -->
                <!--   <div class="panel-body col-md-7">
                    <div class="adv-table editable-table ">
                        <div class="clearfix">
                            <div class="col-lg-12">
                                <section class="panel">
                                    <div class="panel-body">
                                        <div class="col-lg-12">
                                            
                                        </div>
                                        
                                        
                                        <input type="hidden" name="id" value='<?php
                                        if (!empty($nurse->id)) {
                                        echo $nurse->id;
                                        }
                                        ?>'>
                                        <button type="submit" name="submit" class="btn btn-info"><?php echo lang('submit'); ?></button>
                                    </form>
                                </div>
                            </section>
                        </div>
                    </div>
                </div>
            </div> -->
            
            <div class="panel-body col-md-12">
                <div class="card">
                    
                    <div class="card-header">
                        <h3 class="font-weight-bold"> <?php
                        echo lang('New Assessment');
                        ?></h3>
                    </div>
                    <div class="card-content">
                        <div class="card-body">
                            <div class="col-lg-3"></div>
                            <div class="col-md-12">


                            <form role="form" action="initial_assessment/saveAssessment?id=<?php echo $_GET['id']; ?>" method="post" enctype="multipart/form-data" name="newGenInfo" onsubmit="return validateForm1()">
                                <div class="accordion" id="accordionExample">

                                  <!-- patient visit record start -->
                                  <div class="card">
                                    <div class="card-header" id="headingOne">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link" type="button" data-toggle="collapse" data-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
                                          <h3 class="font-weight-bold">Patient Visit Record</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseOne" class="collapse show" aria-labelledby="headingOne" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Date'); ?></label>
                                                    <input required type="date" class="form-control futDateNonAccept" name="pvrDate" value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('day'); ?></label>
                                                    <select class="form-control" name="pvrDay" id="pvrDay" required>
                                                        <option value="" selected>Choose...</option>
                                                        <option value="Monday">Monday</option>
                                                        <option value="Tuesday">Tuesday</option>
                                                        <option value="Wednessday">Wednesday</option>
                                                        <option value="Thursday">Thursday</option>
                                                        <option value="Friday">Friday</option>
                                                        <option value="Saturday">Saturday</option>
                                                        <option value="Sunday">Sunday</option>
                                                    </select>
                                                </div>
                                            </div>
                                        </div>
                                        
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Time in'); ?></label>
                                                    
                                                    <input type="time" class="form-control" name="pvrTimeIn" required>
                                                </div>
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Time out'); ?></label>
                                                    <input type="time" class="form-control" name="pvrTimeOut" required>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Patients Name'); ?></label>
                                                    <input type="text" class="form-control"    name="patientName"  required value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Date of Birth'); ?></label>
                                                    <input type="date" class="form-control futDateNonAccept" required name="dob" id="ptdob">
                                                </div>
                                                
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Diagnosis'); ?></label>
                                                    <input type="text" class="form-control" required name="pvrDiagnosis" value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Allergy'); ?></label>
                                                    <input type="text" class="form-control" required name="pvrAllergy">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('MD Name'); ?></label>
                                                    <input type="text" class="form-control" required name="pvrMd" value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Id Confirmed'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="ID_confirmed" id="radio" value="option1" checked>
                                                        <label class="form-check-label" for="YES">
                                                            YES
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="ID_confirmed" id="radio" value="option2">
                                                        <label class="form-check-label" for="NO">
                                                            NO
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('MD Contact Info'); ?></label>
                                                    <input type="text" class="form-control" required name="pvrMdcntInfo" value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Reason'); ?></label>
                                                    <select class="form-control" name="pvrReason" id="inputGroupSelect01" required>
                                                        <option selected value="Scheduled">Scheduled</option>
                                                        <option value="Call">Call</option>
                                                    </select>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" class="required"><?php echo lang('Type of therapy'); ?></label>
                                                    <select class="form-control" name="therapy_type" id="therapy_type" required>
                                                        <option selected>Choose...</option>
                                                        <?php foreach ($therapyType as $value) { ?>
                                                        <option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
                                                        <?php } ?>
                                                        <option selected value="Other type therapy">Other type therapy</option>
                                                        <option value="Type of therapy drugs">Type of therapy drugs</option>
                                                        <option value="Type of therapy cycle">Type of therapy cycle</option>
                                                        <option value="Type of therapy formula">Type of therapy formula</option>
                                                        <option value="Reason For Visit">Reason For Visit</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="typeAccValInp">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Visit activity'); ?></label>
                                                    <select class="form-control" name="pvrVisitActivity" id="pvrVisitActivity">
                                                        <option value="Administration">Administration</option>
                                                        <option value="Assessment">Assessment</option>
                                                        <option value="Skilled Assessment">Skilled Assessment</option>
                                                        <option value="Access Related">Access Related</option>
                                                        <option value="Catheter Care">Catheter Care</option>
                                                        <option value="Cassette Change">Cassette Change</option>
                                                        <option value="Catheter Declotting">Catheter Declotting</option>
                                                        <option value="Clinical Change">Clinical Change</option>
                                                        <option value="Delivery/Pick-Up Only">Delivery/Pick-Up Only</option>
                                                        <option value="Delivery of Supplies">Delivery of Supplies</option>
                                                        <option value="Delivery of Equipment">Delivery of Equipment</option>
                                                        <option value="Delivery of Medications">Delivery of Medications</option>
                                                        <option value="Discharge Visit">Discharge Visit</option>
                                                        <option value="Dressing Change">Dressing Change</option>
                                                        <option value="Initial Patient Assessment">Initial Patient Assessment</option>
                                                        <option value="Implanted Pump Refill">Implanted Pump Refill</option>
                                                        <option value="Lab Draw">Lab Draw</option>
                                                        <option value="Medication Adminstration">Medication Adminstration</option>
                                                        <option value="Midline Insertion">Midline Insertion</option>
                                                        <option value="Order Change">Order Change</option>
                                                        <option value="Orientation/Training Visit">Orientation/Training Visit</option>
                                                        <option value="Port Access Insertion">Port Access Insertion</option>
                                                        <option value="PICC Insertion">PICC Insertion</option>
                                                        <option value="PIV Insertion">PIV Insertion</option>
                                                        <option value="Patient Training (IV Related)">Patient Training (IV Related)</option>
                                                        <option value="Patient Training (Non-IV Related)">Patient Training (Non-IV Related)</option>
                                                        <option value="Pump Problem">Pump Problem</option>
                                                        <option value="Routine Visit">Routine Visit</option>
                                                        <option value="Subcutaneous Access Insertion">Subcutaneous Access Insertion</option>
                                                        <option value="Supervisory Visit">Supervisory Visit</option>
                                                        <option value="Teaching">Teaching</option>
                                                        <option value="Wound Care">Wound Care</option>
                                                    </select>
                                                </div>
                                                
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Types Of Device Access'); ?></label>
                                                    <select type="text" class="form-control" name="PVRtypesOfDeviceAccess" id="deviceAccessType">
                                                        <option selected>Choose...</option>
                                                        <option value="Enteral Type">Enteral Type</option>
                                                        <option value="PICC Exposed Length">PICC Exposed Length</option>
                                                        <option value="Number Of Lumens">Number Of Lumens</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="deviceAccessTypeDiv">
                                                    
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Access Assessment'); ?></label>
                                                    <select class="form-control" name="accessAssessmentDD" id="accessAssessmentDD">
                                                        <option selected value="">please select an option</option>
                                                        <option value="Comments">Comments</option>
                                                        <option value="CARE DID NOT OCCUR">CARE DID NOT OCCUR</option>
                                                        <option value="NON-BILLABLE VISIT">NON-BILLABLE VISIT</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="accessAssessmentDiv">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Action'); ?></label>
                                                    <select class="form-control" name="action" id="action">
                                                        <option value="N/A">N/A</option>
                                                        <option value="Injection Cap Device Change">Injection Cap Device Change</option>
                                                        <option value="Dressing Change">Dressing Change</option>
                                                        <option value="Blood Return">Blood Return</option>
                                                        <option value="Flushed With 0.9% Nacl">Flushed With 0.9% Nacl</option>
                                                        <option value="Flushed With Heparin">Flushed With Heparin</option>
                                                        <option value="Huber Device Type">Huber Device Type</option>
                                                        <option value="Huber Device Accessed">Huber Device Accessed</option>
                                                        <option value="Huber Device Deaccessed">Huber Device Deaccessed</option>
                                                        <option value="Huber Device Flushed without Reistance">Huber Device Flushed without Reistance</option>
                                                        <option value="Access Type">Access Type</option>
                                                        <option value="Access To Vein">Access To Vein</option>
                                                        <option value="Device Name">Device Name</option>
                                                        <option value="Device Size">Device Size</option>
                                                        <option value="Lab Work Obtained">Lab Work Obtained</option>
                                                        <option value="Peripheral Site">Peripheral Site</option>
                                                        <option value="Via Central Line">Via Central Line</option>
                                                        <option value="Lab Sheet Tracking Sticker">Lab Sheet Tracking Sticker</option>
                                                        <option value="Subcutaneous Site Change">Subcutaneous Site Change</option>
                                                        <option value="Subcutaneous Location">Subcutaneous Location</option>
                                                        <option value="Subcutaneous Name">Subcutaneous Name</option>
                                                        <option value="Subcutaneous Site">Subcutaneous Site</option>
                                                        <option value="Pump Function">Pump Function</option>
                                                        <option value="Pump Function Model Number">Pump Function Model Number</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-8" id="actionDiv">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Pump Battery charge'); ?></label>
                                                    <input type="number" class="form-control" name="pumpBetteryCharge" value="<?php echo set_value('fname'); ?>">
                                                </div>
                                                
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Pump Res Volume'); ?></label>
                                                    <input type="number" class="form-control" name="pumpRexVolume">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Pump Infusion Volume'); ?></label>
                                                    <input type="text" class="form-control" name="pumpInfusionVolume" id="pumpInfusionVolume">
                                                    
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Pump Rate'); ?></label>
                                                    <select class="form-control" name="pumpRate" id="pumpRate">
                                                        <option value="Mg">Mg</option>
                                                        <option value="ml">ml</option>
                                                        <option value="times per hour">times per hour</option>
                                                        <option value="times daily">times daily</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="pumpRateDiv">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Bolus'); ?></label>
                                                    
                                                    <input type="text" class="form-control" name="pvrBolus">
                                                </div>
                                                <div class="col-lg-3">
                                                    <label for="exampleInputEmail1" ><?php echo lang('KVO'); ?></label>
                                                    <input type="time" class="form-control" name="pvrKVO">
                                                </div>
                                                <div class="col-lg-3">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Taper'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="pvrTaper" id="radio" value="UP" checked>
                                                        <label class="form-check-label" for="YES">
                                                            UP
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="pvrTaper" id="radio" value="DOWN">
                                                        <label class="form-check-label" for="NO">
                                                            DOWN
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-6">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Program Verified With'); ?></label>
                                                    <input type="text"  class="form-control" name="Program_Verified_With">
                                                </div>
                                            </div>
                                        </div>

                                      </div>
                                    </div>
                                  </div>
                                  <!-- patient visit record end -->

                                  <!-- patient PHYSICAL ASSESSMENT start -->
                                  <div class="card">
                                    <div class="card-header" id="headingTwo">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                          <h3 class="font-weight-bold">PHYSICAL ASSESSMENT</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('VITAL SIGNS'); ?></label>
                                                    <select class="form-control" name="phyAssVitalSign" id="phyAssVitalSign">
                                                        <option value="Temperature">Temperature</option>
                                                        <option value="Pulse">Pulse</option>
                                                        <option value="Blood Pressure">Blood Pressure</option>
                                                        <option value="SpO2">SpO2</option>
                                                        <option value="Respiration">Respiration</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Vital Signs Measurements'); ?></label>
                                                    <textarea class='form-control' name='vital_Sign_measurement' id=''></textarea>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('CARDIOVASCULAR'); ?></label>
                                                        <select class="form-control" name="cardiovascular" id="cardiovascular">    <option value="" selected>Choose...</option>
                                                        <option value="Rhythm">Rhythm</option>
                                                        <option value="Edema">Edema</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="CvacRhythm" style="display: none;">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Rhythm'); ?></label>
                                                    <select class="form-control" name="CvacRhythm" id="">
                                                        <option value="" selected>Choose...</option>
                                                        <option value="Regular">Regular</option>
                                                        <option value="Irregular">Irregular</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="cvacEdema" style="display: none;">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
                                                    <select class="form-control" name="cvacEdema" id="">
                                                        <option value="Absent">Absent</option>
                                                        <option value="Present">Present</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                    <textarea class="form-control" name="cvacNotes" id="cvacNotes"></textarea>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('RESPIRATORY'); ?></label>
                                                    <select class="form-control" name="respiratory" id="respiratory">
                                                        <option value="Within Normal Limits (WNL)">Within Normal Limits (WNL)</option>
                                                        <option value="Breath Sounds">Breath Sounds</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4" id="respBreathSound" style="display: none;">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Breath Sounds'); ?></label>
                                                    <select class="form-control" name="respBreathSound" id="">
                                                        <option value="Diminished">Diminished</option>
                                                        <option value="Rales">Rales</option>
                                                        <option value="Wheeze">Wheeze</option>
                                                        <option value="SOB At Rest">SOB At Rest</option>
                                                        <option value="SOB on Exertion">SOB on Exertion</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                    <textarea class="form-control" name="respNotes" id="respNotes"></textarea>
                                                </div>
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                  </div>
                                  <!-- patient PHYSICAL ASSESSMENT end -->

                                  <!-- patient FOODS/FLUIDS start -->
                                  <div class="card">
                                    <div class="card-header" id="headingThree">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">
                                          <h3 class="font-weight-bold">FOODS/FLUIDS</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseThree" class="collapse" aria-labelledby="headingThree" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Food'); ?></label>
                                                        <select class="form-control" name="foodDiet" id="foodDiet">
                                                            <option selected value="Regular">Regular</option>
                                                            <option value="No Deficit">No Deficit</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="dietType" id="radio" value="Compliant" checked>
                                                            <label class="form-check-label" for="Compliant">
                                                                Compliant
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="dietType" id="radio" value="Non Compliant">
                                                            <label class="form-check-label" for="Non Compliant">
                                                                Non Compliant
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Fluid'); ?></label>
                                                        <select class="form-control" name="fluidDiet" id="fluidDiet">
                                                            <option selected value="Regular">Regular</option>
                                                            <option value="No Deficit">No Deficit</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="fluidType" id="radio" value="Compliant" checked>
                                                            <label class="form-check-label" for="Compliant">
                                                                Compliant
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="fluidType" id="radio" value="Non Compliant">
                                                            <label class="form-check-label" for="Non Compliant">
                                                                Non Compliant
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Fluid Intake'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="fluidIntake" id="radio" value="Adequate" checked>
                                                            <label class="form-check-label" for="Compliant">
                                                                Adequate
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="fluidIntake" id="radio" value="Inadequate">
                                                            <label class="form-check-label" for="Non Compliant">
                                                                Inadequate
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Weight Amount'); ?></label>
                                                        <select class="form-control" name="WeightAmount" id="WeightAmount">
                                                            <?php for ($i=1; $i < 500 ; $i++) { ?>
                                                            <option selected value="<?=$i?>"><?=$i?> LBS</option>
                                                            <?php } ?>
                                                            <!-- <option selected value="Regular">Regular</option> -->
                                                            
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="WeightGainType" id="radio" value="Compliant" checked>
                                                            <label class="form-check-label" for="Compliant">
                                                                Gain
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="WeightGainType" id="radio" value="Non Compliant">
                                                            <label class="form-check-label" for="Non Compliant">
                                                                Loss
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                        <div class="form-check">
                                                            <textarea class='form-control' name="WeightComments"></textarea>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>    
                                      </div>
                                    </div>
                                  </div>
                                  <!-- patient FOODS/FLUIDS end -->

                                  <!-- patient ENDOCRINE starts -->
                                  <div class="card">
                                    <div class="card-header" id="headingFour">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapsefour" aria-expanded="false" aria-controls="collapsefour">
                                          <h3 class="font-weight-bold">ENDOCRINE</h3>
                                        </button>
                                      </h2>
                                    </div>

                                    <div id="collapsefour" class="collapse" aria-labelledby="headingOne" data-parent="#accordionExample"  aria-expanded="false" >
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
                                                    <div class="form-check form-check-inline">
                                                        <input class="form-check-input" name="ENDOCRINE" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                        <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Diabetes'); ?></label>
                                                    <input type="text" class='form-control' name='Diabetes' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Blood Sugar(MG/dl)'); ?></label>
                                                    <input type="number" class='form-control' name='bloodSugarMeasure' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                    <div class="form-check">
                                                        <textarea class='form-control' name="DiabetesComments"></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                </div>


                                    <div class="card">
                                        <div class="card-header" id="headingFive">
                                          <h2 class="mb-0">
                                            <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFive" aria-expanded="false" aria-controls="collapseFive">
                                              <h3 class="font-weight-bold">ACTIVITY/REST</h3>
                                            </button>
                                          </h2>
                                        </div>
                                        <div id="collapseFive" class="collapse" aria-labelledby="headingFive" data-parent="#accordionExample">
                                          <div class="card-body">
                                            <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-4">
                                                            <!-- <label for="exampleInputEmail1" ><?php echo lang('ACTIVITY/REST'); ?></label> -->
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-check-input" name="ENDOCRINE" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                                <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                            </div>
                                                        </div>
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Musculosketal'); ?></label>
                                                            <input type="text" class='form-control' name='Musculosketal' id=''>
                                                        </div>
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Activity'); ?></label>
                                                            <div class="form-check">
                                                                <textarea class='form-control' name="MusculosketalActivity"></textarea>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>

                                                <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-4">
                                                            <!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-check-input" name="ARprom" type="checkbox" id="promExercises" value="After Feed">
                                                                <label class="form-check-label" for="inlineCheckbox2">Encouraged PROM exercises to extremeties</label>
                                                            </div>
                                                        </div>
                                                        <div class="col-lg-4">
                                                            <!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-check-input" name="ambulatoryAr" type="radio" id="promExercises" value="After Feed">
                                                                <label class="form-check-label" for="inlineCheckbox2">Ambulatory</label>
                                                            </div>
                                                            
                                                            <!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-check-input" name="ambulatoryAr" type="radio" id="promExercises" value="After Feed">
                                                                <label class="form-check-label" for="inlineCheckbox2">Non Ambulatory</label>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Dependent'); ?></label>
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-control" name="DependentAR" type="text" id="inlineCheckbox3" value="">
                                                            </div>
                                                        </div>
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('wheelChair'); ?></label>
                                                            <input type="text" class='form-control' name='wheelChairAR' id=''>
                                                        </div>
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                            <div class="form-check">
                                                                <textarea class='form-control' name="CommentsAR"></textarea>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                          </div>
                                        </div>
                                  </div>


                                  <div class="card">
                                    <div class="card-header" id="headingSix">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSix" aria-expanded="false" aria-controls="collapseSix">
                                          <h3 class="font-weight-bold">PAIN</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseSix" class="collapse" aria-labelledby="headingSix" data-parent="#accordionExample">
                                      <div class="card-body">
                                                <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-5">
                                                            <img width="300" src="https://www.disabled-world.com/pics/1/pain-scale-chart-3.gif">
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-2">
                                                            <!-- <label for="exampleInputEmail1" ><?php echo lang('ACTIVITY/REST'); ?></label> -->
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-check-input" name="painDeflict" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                                <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                            </div>
                                                        </div>
                                                        <div class="col-lg-6">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Pain level assessed'); ?></label>
                                                            <select class="form-control" name="painLevelAssessed" id="">
                                                                <option value="0">0 No pain</option>
                                                                <option value="1">1</option>
                                                                <option value="2">2</option>
                                                                <option value="3">3</option>
                                                                <option value="4">4</option>
                                                                <option value="5">5</option>
                                                                <option value="6">6</option>
                                                                <option value="7">7</option>
                                                                <option value="8">8</option>
                                                                <option value="9">9</option>
                                                                <option value="10">10 Sever pain</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-lg-2">
                                                            <label for="exampleInputEmail1" ><?php echo lang('type'); ?></label>
                                                            <div class="form-check">
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Accute">
                                                                    <label class="form-check-label" for="typePainAccute">Accute</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Constant">
                                                                    <label class="form-check-label" for="typePainConstant">Constant</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Sporatic">
                                                                    <label class="form-check-label" for="typePainSporatic">Sporatic</label>
                                                                </div>
                                                            </div>
                                                        </div>
                                                        <div class="col-lg-2">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Quality'); ?></label>
                                                            <div class="form-check">
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="After Feed">
                                                                    <label class="form-check-label" for="typePainAching">Aching</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Throbbing">
                                                                    <label class="form-check-label" for="typePainThrobbing">Throbbing</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Pressure">
                                                                    <label class="form-check-label" for="typePainPressure">Pressure</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Sharp">
                                                                    <label class="form-check-label" for="typePainSharp">Sharp</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Burnig">
                                                                    <label class="form-check-label" for="typePainBurnig">Burnig</label>
                                                                </div>
                                                                <div class="form-check form-check-inline">
                                                                    <input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Dull">
                                                                    <label class="form-check-label" for="typePainDull">Dull</label>
                                                                </div>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <div class="row">
                                                        <div class="col-lg-4">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Relief From'); ?></label>
                                                            <div class="form-check form-check-inline">
                                                                <input class="form-control" name="ReliefFrom" type="text" id="" value="">
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                      </div>
                                    </div>
                                  </div>



                                  <div class="card">
                                    <div class="card-header" id="headingSeven">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSeven" aria-expanded="false" aria-controls="collapseSeven">
                                          <h3 class="font-weight-bold">SKIN</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseSeven" class="collapse" aria-labelledby="headingSeven" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('skin'); ?></label>
                                                    <div class="form-check form-check-inline">
                                                        <select class="form-control" name="skin" id="">
                                                            <option value="Warm">Warm</option>
                                                            <option value="Dry">Dry</option>
                                                            <option value="Intact">Intact</option>
                                                            <option value="Rash">Rash</option>
                                                            <option value="Puritis">Puritis</option>
                                                        </select>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Describe'); ?></label>
                                                    <div class="form-check form-check-inline">
                                                        <input class="form-control" name="skinDescribe" type="text" id="" value="">
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Bruises Location'); ?></label>
                                                    <div class="form-check form-check-inline">
                                                        <input class="form-control" name="skinBruisesLocation" type="text" id="" value="">
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Surgical Site'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Clean" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Clean
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Dry">
                                                        <label class="form-check-label" for="NO">
                                                            Dry
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Wound'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Clean" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Clean
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Dry">
                                                        <label class="form-check-label" for="NO">
                                                            Dry
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                    <textarea class='form-control' name='skinComments' id=''></textarea>
                                                </div>
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                  </div>


                                  <div class="card">
                                    <div class="card-header" id="headingEight">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEight" aria-expanded="false" aria-controls="collapseEight">
                                          <h3 class="font-weight-bold">CIRCULATION</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseEight" class="collapse" aria-labelledby="headingEight" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="circulationDecifit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                            <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Chest Pain'); ?></label>
                                                        <textarea class='form-control' name='circCheastPain' id=''></textarea>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="circEdema" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="circEdema" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Location'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <select class="form-control" name="circLocation" id="">
                                                                <option value="Warm">Warm</option>
                                                                <option value="Dry">Dry</option>
                                                                <option value="Intact">Intact</option>
                                                                <option value="Rash">Rash</option>
                                                                <option value="Puritis">Puritis</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <!-- <label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label> -->
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="circEdema" id="radio" value="Pitting" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Pitting
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="circEdema" id="radio" value="Non Pitting">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Peripheral Capillary Refill'); ?></label>
                                                        <textarea class='form-control' name='peripheralCapilaryRefill' id=''></textarea>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Circulation Status'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <select class="form-control" name="CirculationStatus" id="">
                                                                <option value="Good (less than 3 seconds)">Good (less than 3 seconds)</option>
                                                                <option value="Fair (3-5 seconds)">Fair (3-5 seconds)</option>
                                                                <option value="Poor (greater than 5 seconds)">Poor (greater than 5 seconds)</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                        <textarea class='form-control' name='Circulation_Comments' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                  </div>


                                <div class="card">
                                    <div class="card-header" id="headingNine">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseNine" aria-expanded="false" aria-controls="collapseNine">
                                          <h3 class="font-weight-bold">VENTILATION</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseNine" class="collapse" aria-labelledby="headingNine" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="ventilationDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                            <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator Type'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <select class="form-control" name="ventilatorType" id="">
                                                                <option value="vent 1">vent 1</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Breath Sounds'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <select class="form-control" name="BreathSounds" id="">
                                                                <option value="Rales">Rales</option>
                                                                <option value="Diminished">Diminished</option>
                                                                <option value="Rhonchi">Rhonchi</option>
                                                                <option value="Wheezing">Wheezing</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('SOB'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                At Rest
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                On Exertion
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                Cough
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                Productive
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                Dry
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Color'); ?></label>
                                                        <select class="form-control" name="ventilatorColor" id="">
                                                            <option value="Red">Red</option>
                                                            <option value="grren">Green</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator Settings'); ?></label>
                                                        <input type="text" class='form-control' name='ventilatorSetting' id=''>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator Mode'); ?></label>
                                                        <select class="form-control" name="ventilatorMode" id="">
                                                            <option value="SIMV">SIMV</option>
                                                        </select>
                                                    </div>
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator TV'); ?></label>
                                                        <textarea class='form-control' name='ventilatorTv' id=''></textarea>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator Pressure'); ?></label>
                                                        <select class="form-control" name="ventilatorPressure" id="">
                                                            <option value="High">High</option>
                                                            <option value="Low">Low</option>
                                                        </select>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator BR'); ?></label>
                                                        <input type="text" class="form-control" name="ventilatorBR" id="">
                                                    </div>
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Ventilator Oxygen Mesured In L/Min '); ?></label>
                                                        <input type="text" class='form-control' name='ventilatorOxygenMeasure' id=''>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Inspiratory Time'); ?></label>
                                                        <select class="form-control" name="ventilatorInspiratoryTime" id="">
                                                            <?php for ($i=1; $i < 60 ; $i++) { ?>
                                                            <option selected value="<?=$i?>"><?=$i?> Sec</option>
                                                            <?php } ?>
                                                        </select>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Oximeter Frequency'); ?></label>
                                                        <textarea class="form-control" name="OximeterFrequency" id=""></textarea>
                                                    </div>
                                                    
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Oximeter Paramteres'); ?></label>
                                                        <textarea class='form-control' name='oximeterParameter' id=''></textarea>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Other'); ?></label>
                                                        <textarea class='form-control' name='ventilatorOtherNote' id=''></textarea>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Vent Dependent'); ?></label>
                                                        <select class="form-control" name="ventDependent" id="">
                                                            <option selected value="a">a</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                        <textarea class="form-control" name="ventilatorComments" id=""></textarea>
                                                    </div>
                                                    
                                                </div>
                                            </div>        
                                      </div>
                                    </div>
                                </div>


                            <div class="card">
                                <div class="card-header" id="headingTen">
                                  <h2 class="mb-0">
                                    <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTen" aria-expanded="false" aria-controls="collapseTen">
                                      <h3 class="font-weight-bold">TRACHEOTOMY CARE</h3>
                                    </button>
                                  </h2>
                                </div>
                                <div id="collapseTen" class="collapse" aria-labelledby="headingTen" data-parent="#accordionExample">
                                  <div class="card-body">
                                    <div class="form-group">
                                        <div class="row">
                                            <div class="col-lg-4">
                                                <label for="exampleInputEmail1" ><?php echo lang('Tracheotomy Care Required'); ?></label>
                                                <select class="form-control" name="TracheotomyCareRequired" id="">
                                                    <option value="Change">Change</option>
                                                    <option value="Sterile">Sterile</option>
                                                    <option value="Clean">Clean</option>
                                                </select>
                                            </div>
                                        </div>
                                    </div>
                                  </div>
                                </div>
                            </div>


                              <div class="card">
                                <div class="card-header" id="headingEleven">
                                  <h2 class="mb-0">
                                    <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEleven" aria-expanded="false" aria-controls="collapseEleven">
                                      <h3 class="font-weight-bold">MD Orders</h3>
                                    </button>
                                  </h2>
                                </div>
                                <div id="collapseEleven" class="collapse" aria-labelledby="headingEleven" data-parent="#accordionExample">
                                  <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MdOrderNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Excoriation'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachExcoriation" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachExcoriation" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MDTrachExcoriationNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Drainage'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachDrainage" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachDrainage" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MDTrachDrainageNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Redness At Trach Site'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MDredNessAtTrachSiteNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Inner Cannula Changed'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MDTrachInnerCannulaChangedMdOrderNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Connector Size'); ?></label>
                                                        <input type="text" class="form-control" name="MDtrachConnectorSize" id="">
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Connector Length'); ?></label>
                                                        <input type="text" class="form-control" name="MDtrachConnectorLength" id="">
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Suction'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDtrachSuction" id="radio" value="option1" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDtrachSuctions" id="radio" value="option2">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="MDTrachSuctionnotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Suction Type'); ?></label>
                                                        <select class="form-control" name="MDtrachSuctionType" id="">
                                                            <option value="Oral">Oral</option>
                                                            <option value="Nasal">Nasal</option>
                                                            <option value="Tracheal">Tracheal</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Suction Catheter Kit'); ?></label>
                                                        <input type="text" class="form-control" name="MDtrachSuctionCatherKit" id="">
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Trach Suciton Catheter Kit Size'); ?></label>
                                                        <input type="text" class="form-control" name="MDtrachCAthertarKitSize">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="CateterKitNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </div>


                                <div class="card">
                                    <div class="card-header" id="headingTwelve">
                                        <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwelve" aria-expanded="false" aria-controls="collapseTwelve">
                                            <h3 class="font-weight-bold">GASTROINTESTINAL</h3>
                                        </button>
                                        </h2>
                                    </div>
                                    <div id="collapseTwelve" class="collapse" aria-labelledby="headingTwelve" data-parent="#accordionExample">
                                        <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="GASTROINTESTINALnoDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                            <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('GASTROINTESTINAL'); ?></label>
                                                        <select class="form-control" name="GASTROINTESTINAL" id="">
                                                            <option value="Bowel Sound Audible">Bowel Sound Audible</option>
                                                            <option value="Nausea">Nausea</option>
                                                            <option value="Vomiting">Vomiting</option>
                                                            <option value="Diarrhea">Diarrhea</option>
                                                            <option value="Anorexia">Anorexia</option>
                                                            <option value="Dysphagia">Dysphagia</option>
                                                            <option value="Thrust">Thrust</option>
                                                            <option value="Stomatits">Stomatits</option>
                                                            <option value="Constipation">Constipation</option>
                                                            <option value="Abd Soft/Nontender">Abd Soft/Nontender</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Date of Last Bowel Movement'); ?></label>
                                                        <input type="date" class="form-control" name="DateLastBowelMovement">
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                        <textarea class="form-control" name="DateLastBowelMovementComment"></textarea>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </div>



                                <div class="card">
                                    <div class="card-header" id="headingThirteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseThirteen" aria-expanded="false" aria-controls="collapseThirteen">
                                            <h3 class="font-weight-bold">GENITOURINARY</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseThirteen" class="collapse" aria-labelledby="headingThirteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('GENITOURINARY'); ?></label>
                                                    <select class="form-control" name="GENITOURINARY" id="">
                                                        <option value="Burning">Burning</option>
                                                        <option value="Hematuria">Hematuria</option>
                                                        <option value="Odor">Odor</option>
                                                        <option value="Urgency">Urgency</option>
                                                    </select>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Color'); ?></label>
                                                    <select class="form-control" name="GENITOURINARYColor" id="">
                                                        <option value="red">red</option>
                                                        
                                                    </select>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Cathertar'); ?></label>
                                                    
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" onclick="ifInweldingFun(this)" name="Cathertar" id="radio" value="Indwelling" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Indwelling
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" onclick="ifInweldingFun(this)" name="Cathertar" id="radio" value="Staight Catheter">
                                                        <label class="form-check-label" for="NO">
                                                            Staight Catheter
                                                        </label>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                        </div>
                                        <script type="text/javascript">
                                        function ifInweldingFun(_this){
                                        var val = _this.value;
                                        if(val == 'Indwelling')
                                        {
                                        document.getElementById("cathBalOrfr").style.display = "block";
                                        
                                        }
                                        if(val == 'Staight Catheter')
                                        {
                                        document.getElementById("cathBalOrfr").style.display = "none";
                                        
                                        }
                                        }
                                        </script>
                                        <div class="form-group">
                                            <div class="row" id="cathBalOrfr" style="display: none;">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('If Indwelling'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Fr" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Fr
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Ballon">
                                                        <label class="form-check-label" for="NO">
                                                            Ballon
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                    <textarea class="form-control" name="GENITOURINARYNotes" id=""></textarea>
                                                </div>
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                </div>   


                                <div class="card">
                                    <div class="card-header" id="headingFourteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFourteen" aria-expanded="false" aria-controls="collapseFourteen">
                                          <h3 class="font-weight-bold">HYGINENE</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseFourteen" class="collapse" aria-labelledby="headingFourteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <div class="form-check form-check-inline">
                                                        <input class="form-check-input" name="HYGINENEnoDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                        <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('HYGINENE'); ?></label>
                                                    <select class="form-control" name="HYGINENE" id="">
                                                        <option value="Adequate">Adequate</option>
                                                        <option value="Inadequate">Inadequate</option>
                                                        <option value="Self Care">Self Care</option>
                                                        <option value="Needs Assistance">Needs Assistance</option>
                                                    </select>
                                                </div>
                                                
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                </div>     


                                <div class="card">
                                    <div class="card-header" id="headingFifteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFifteen" aria-expanded="false" aria-controls="collapseFifteen">
                                            <h3 class="font-weight-bold">INTEGUMENTARY</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseFifteen" class="collapse" aria-labelledby="headingFifteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('INTEGUMENTARY'); ?></label>
                                                        <select class="form-control" name="INTEGUMENTARY" id="">
                                                            <option value="Color">Color</option>
                                                            <option value="Temperature">Temperature</option>
                                                            <option value="Turgor">Turgor</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Color Vairables'); ?></label>
                                                        <select class="form-control" name="INTEGUMENTARYColorVairables" id="">
                                                            <option value="Pink">Pink</option>
                                                            <option value="Pale">Pale</option>
                                                            <option value="Gray">Gray</option>
                                                            <option value="Jaundice">Jaundice</option>
                                                            <option value="Other Describe">Other Describe</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Temperature Variables'); ?></label>
                                                        <select class="form-control" name="INTEGUMENTARYTemperatureVariables" id="">
                                                            <option value="Warm">Warm</option>
                                                            <option value="Dry">Dry</option>
                                                            <option value="Cool">Cool</option>
                                                            <option value="Diaphoretic">Diaphoretic</option>
                                                            <option value="Other Describe">Other Describe</option>
                                                        </select>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Turgor Variables'); ?></label>
                                                        <select class="form-control" name="INTEGUMENTARYTurgorVariables" id="">
                                                            <option value="Good">Good</option>
                                                            <option value="Fair">Fair</option>
                                                            <option value="Poor">Poor</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="INTEGUMENTARYNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                </div>      


                                <div class="card">
                                    <div class="card-header" id="headingSixteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSixteen" aria-expanded="false" aria-controls="collapseSixteen">
                                          <h3 class="font-weight-bold">NERUOLOGICAL</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseSixteen" class="collapse" aria-labelledby="headingSixteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-2">
                                                        <!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="NERUOLOGICALnoDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                            <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Status'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Disoriented">
                                                            <label class="form-check-label" for="inlineCheckbox2">Disoriented</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Memory Intact">
                                                            <label class="form-check-label" for="inlineCheckbox2">Memory Intact</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Headache">
                                                            <label class="form-check-label" for="inlineCheckbox2">Headache</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Confused">
                                                            <label class="form-check-label" for="inlineCheckbox2">Confused</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Forgetful">
                                                            <label class="form-check-label" for="inlineCheckbox2">Forgetful</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Activity'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Ad Lib">
                                                            <label class="form-check-label" for="inlineCheckbox2">Ad Lib</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Up with Assistance">
                                                            <label class="form-check-label" for="inlineCheckbox2">Up with Assistance</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Bedrest">
                                                            <label class="form-check-label" for="inlineCheckbox2">Bedrest</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Equipment">
                                                            <label class="form-check-label" for="inlineCheckbox2">Equipment</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="NEUROLOGICALnotes" id=""></textarea>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                </div>     


                                <div class="card">
                                    <div class="card-header" id="headingSeventeen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSeventeen" aria-expanded="false" aria-controls="collapseSeventeen">
                                          <h3 class="font-weight-bold">PSYCHOLOGICAL / EMOTIONAL REACTION</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseSeventeen" class="collapse" aria-labelledby="headingSeventeen" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-2">
                                                        <!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="phycholEmotionalNodeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
                                                            <label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Social Support System'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Adequate">
                                                            <label class="form-check-label" for="inlineCheckbox2">Adequate</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Calm">
                                                            <label class="form-check-label" for="inlineCheckbox2">Calm</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Anxious">
                                                            <label class="form-check-label" for="inlineCheckbox2">Anxious</label>
                                                        </div>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Depressed">
                                                            <label class="form-check-label" for="inlineCheckbox2">Depressed</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Copes Effectively with Therapy'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="phyEmocopesEffWithTherapy" id="radio" value="YE" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="phyEmocopesEffWithTherapy" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Copes Effectively with Disease'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="phyEmocopesEffWithDieases" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="phyEmocopesEffWithDieases" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="NEUROLOGICALnotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                </div>    


                                <div class="card">
                                    <div class="card-header" id="headingEighteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEighteen" aria-expanded="false" aria-controls="collapseEighteen">
                                          <h3 class="font-weight-bold">SKILLS - KNOWLEDGE ASSESSMENT</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseEighteen" class="collapse" aria-labelledby="headingEighteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Include Family'); ?></label>
                                                        <div class="form-check form-check-inline">
                                                            <input class="form-check-input" name="skillKnowIncludeFamily" type="checkbox" id="inlineCheckbox3" value="Inc">
                                                            <label class="form-check-label" for="inlineCheckbox2">Include Family</label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('TEACHING'); ?></label>
                                                        <select class="form-control" name="skillKnowIncludeTeaching" id="">
                                                            <option value="Ciompliant">Ciompliant</option>
                                                            <option value="Non Compliant">Non Compliant</option>
                                                            <option value="Reinforce Fall & Accident Prevention">Reinforce Fall & Accident Prevention</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="skillKnowIncludeTeachingnotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-4">
                                                        <label for="exampleInputEmail1" ><?php echo lang('LEARNING'); ?></label>
                                                        <select class="form-control" name="skillKnowIncludeLearning" id="">
                                                            <option value="Ciompliant">Ciompliant</option>
                                                            <option value="Non Compliant">Non Compliant</option>
                                                            <option value="Reinforce Fall & Accident Prevention">Reinforce Fall & Accident Prevention</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="skillKnowIncludeLearningNotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                </div>


                                <div class="card">
                                    <div class="card-header" id="headingNineteen">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseNineteen" aria-expanded="false" aria-controls="collapseNineteen">
                                          <h3 class="font-weight-bold">RESPONSE TO THERAPY</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseNineteen" class="collapse" aria-labelledby="headingNineteen" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Adverse Medication Side Effects'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="adverseMedicationSideEffects" id="radio" value="Denied" checked>
                                                            <label class="form-check-label" for="Denied">
                                                                Denied
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="adverseMedicationSideEffects" id="radio" value="Confirmed">
                                                            <label class="form-check-label" for="Confirmed">
                                                                Confirmed
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Patient Complain with Medication Thearpy'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="PatientComplainwithMedicationThearpy" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="PatientComplainwithMedicationThearpy" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                        <textarea class="form-control" name="RESPONSETOTHERAPYnotes" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
                                                        <input type="text" class="form-control" name="respTotherapyCaregiver" value="">
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Copes Effectively, with Therapy or Disease process'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="CopesEffectivelywithTherapyorDiseaseprocess" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="CopesEffectivelywithTherapyorDiseaseprocess" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                  </div>  


                            <div class="card">
                                <div class="card-header" id="headingTwo">
                                  <h2 class="mb-0">
                                    <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                      <h3 class="font-weight-bold">MEDICATION</h3>
                                    </button>
                                  </h2>
                                </div>
                                <div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
                                  <div class="card-body">
                                    <div class="form-group">
                                        <div class="row">
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Medication Changes'); ?></label>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="MedicationChanges" id="radio" value="YES" checked>
                                                    <label class="form-check-label" for="YES">
                                                        YES
                                                    </label>
                                                </div>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="MedicationChanges" id="radio" value="NO">
                                                    <label class="form-check-label" for="NO">
                                                        NO
                                                    </label>
                                                </div>
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Review Medication Profile Include Otc'); ?></label>
                                                <input type="text" class="form-control" name="ReviewMedicationProfileIncludeOtc">
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('New Meds'); ?></label>
                                                <input type="text" class="form-control" name="medicationNewMeds">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="form-group">
                                        <div class="row">
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Changes & Effects Reviewed with'); ?></label>
                                                <input type="text" class="form-control" name="ChangesEffectsReviewedwith ">
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
                                                <input type="text" class="form-control" name="medicationCaregiver">
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Use Of Pump'); ?></label>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="medicationUseOfPump" id="radio" value="YES" checked>
                                                    <label class="form-check-label" for="YES">
                                                        YES
                                                    </label>
                                                </div>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="medicationUseOfPump" id="radio" value="NO">
                                                    <label class="form-check-label" for="NO">
                                                        NO
                                                    </label>
                                                </div>
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Prepour Medications By'); ?></label>
                                                <input type="text" class="form-control" name="PrepourMedicationsBy">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="form-group">
                                        <div class="row">
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Job Title'); ?></label>
                                                <select class="form-control" name="medicationJobTitle" id="">
                                                    <option value="HHA">HHA</option>
                                                    <option value="PCA">PCA</option>
                                                    <option value="RN">RN</option>
                                                    <option value="LPN">LPN</option>
                                                </select>
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Patient Independent In Medication Administration'); ?></label>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="PatientIndependentInMedicationAdministration" id="radio" value="YES" checked>
                                                    <label class="form-check-label" for="YES">
                                                        YES
                                                    </label>
                                                </div>
                                                <div class="form-check">
                                                    <input class="form-check-input" type="radio" name="PatientIndependentInMedicationAdministration" id="radio" value="NO">
                                                    <label class="form-check-label" for="NO">
                                                        NO
                                                    </label>
                                                </div>
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('LOT#'); ?></label>
                                                <input type="text" class="form-control" name="MEDICATIONlot">
                                            </div>
                                            <div class="col-lg-3">
                                                <label for="exampleInputEmail1" ><?php echo lang('Expiration Date'); ?></label>
                                                <input type="date" class="form-control" name="MEDICATIONexpirationDate">
                                            </div>
                                            
                                        </div>
                                    </div>
                                  </div>
                                </div>
                            </div>

                            <div class="card">
                            <div class="card-header" id="headingTwenty">
                              <h2 class="mb-0">
                                <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwenty" aria-expanded="false" aria-controls="collapseTwenty">
                                  <h3 class="font-weight-bold">EQUIPMENT</h3>
                                </button>
                              </h2>
                            </div>
                            <div id="collapseTwenty" class="collapse" aria-labelledby="headingTwenty" data-parent="#accordionExample">
                            <div class="card-body">
                                <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-3">
                                            <label for="exampleInputEmail1" ><?php echo lang('EQUIPMENT'); ?></label>
                                            <select class="form-control" name="equipment" id="">
                                                <option value="Hospital Bed">Hospital Bed</option>
                                                <option value="Hoyer Lift">Hoyer Lift</option>
                                                <option value="Motorized Wheel Chair">Motorized Wheel Chair</option>
                                                <option value="Gloves">Gloves</option>
                                                <option value="Bed Pan">Bed Pan</option>
                                                <option value="Other">Other</option>
                                            </select>
                                        </div>
                                        <div class="col-lg-3">
                                            <label for="exampleInputEmail1" ><?php echo lang('Enviornmental Safety'); ?></label>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipmentEnvSafty" id="radio" value="Waste Disposal" checked>
                                                <label class="form-check-label" for="YES">
                                                    Waste Disposal
                                                </label>
                                            </div>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipmentEnvSafty" id="radio" value="Maintain Clear Pathway">
                                                <label class="form-check-label" for="NO">
                                                    Maintain Clear Pathway
                                                </label>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-3">
                                            <label for="exampleInputEmail1" ><?php echo lang('Safety Concerns'); ?></label>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipSafetyConcerns" id="radio" value="YES" checked>
                                                <label class="form-check-label" for="YES">
                                                    YES
                                                </label>
                                            </div>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipSafetyConcerns" id="radio" value="NO">
                                                <label class="form-check-label" for="NO">
                                                    NO
                                                </label>
                                            </div>
                                        </div>
                                        <div class="col-lg-3">
                                            <label for="exampleInputEmail1" ><?php echo lang('WOUND CARE'); ?></label>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipWondscare" id="radio" value="YES" checked>
                                                <label class="form-check-label" for="YES">
                                                    Sterile
                                                </label>
                                            </div>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="equipWondscare" id="radio" value="NO">
                                                <label class="form-check-label" for="NO">
                                                    Clean
                                                </label>
                                            </div>
                                        </div>
                                        
                                    </div>
                                </div>    
                            </div>
                            </div>
                          </div>       


                          <div class="card">
                            <div class="card-header" id="headingTwentyOne">
                              <h2 class="mb-0">
                                <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyOne" aria-expanded="false" aria-controls="collapseTwentyOne">
                                    <h3 class="font-weight-bold">MD Orders</h3>
                                </button>
                              </h2>
                            </div>
                            <div id="collapseTwentyOne" class="collapse" aria-labelledby="headingTwentyOne" data-parent="#accordionExample">
                              <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('MD Orders'); ?></label>
                                                        <textarea class="form-control" name="MDOrdersNotes" id=""></textarea>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Date'); ?></label>
                                                        <input type="date" class="form-control" name="MDOrdersWounddate" id="">
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Type'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersWoundType" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Site Location'); ?></label>
                                                        <textarea class="form-control" name="MDOrdersSiteLocation" id=""></textarea>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Description'); ?></label>
                                                        <textarea class="form-control" name="MDOrdersWoundDesc" id=""></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Measurement'); ?></label>
                                                        <textarea class="form-control" name="MDOrdersWoundMeasurment" id=""></textarea>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Lenghts'); ?></label>
                                                        <span>(In Centimeter)</span>
                                                        <input type="text" class="form-control" name="MDOrdersWoundLength" id="">
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Width'); ?></label>
                                                        <span>(In Centimeter)</span>
                                                        <input type="text" class="form-control" name="MDOrdersWoundWidth" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Diameter'); ?></label>
                                                        <span>(In Centimeter)</span>
                                                        <input type="text" class="form-control" name="MDOrdersWoundDiameter" id="">
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Undermining'); ?></label>
                                                        <span>(In Centimeter)</span>
                                                        <input type="text" class="form-control" name="MDOrdersWoundUndermining" id="">
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Undermining @ Clock Position'); ?></label>
                                                        <input type="time" class="form-control" name="MDOrdersWoundClockPosition" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Cleanse With'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="radio" value="Normal Saline" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Normal Saline
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="radio" value="0.125% Dakins Solution">
                                                            <label class="form-check-label" for="NO">
                                                                0.125% Dakins Solution
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Applications'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="Algisite-M" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Algisite-M
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="4X4 Sterile Gauze">
                                                            <label class="form-check-label" for="NO">
                                                                4X4 Sterile Gauze
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="Santyl Ointment">
                                                            <label class="form-check-label" for="NO">
                                                                Santyl Ointment
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Applied Other'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersAppliedOther" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Covered With'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="4X4 Sterile Gauze" checked>
                                                            <label class="form-check-label" for="YES">
                                                                4X4 Sterile Gauze
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="ExuDry">
                                                            <label class="form-check-label" for="NO">
                                                                ExuDry
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="Derlix">
                                                            <label class="form-check-label" for="NO">
                                                                Derlix
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="Combine/ABDPad">
                                                            <label class="form-check-label" for="NO">
                                                                Combine/ABDPad
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Covered with Other'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersCoverOther" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Secured With'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="Paper Tape" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Paper Tape
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="ACE Bandage">
                                                            <label class="form-check-label" for="NO">
                                                                ACE Bandage
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="Hypafix Tape">
                                                            <label class="form-check-label" for="NO">
                                                                Hypafix Tape
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Packed Wound Bed With'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersPackkedWoundsWithBed" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Status'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Unchanged" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Unchanged
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Healing">
                                                            <label class="form-check-label" for="NO">
                                                                Healing
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Resolveds">
                                                            <label class="form-check-label" for="NO">
                                                                Resolved
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Deterioratings">
                                                            <label class="form-check-label" for="NO">
                                                                Deteriorating
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Granulating'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Excrotic Tissue Present'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Eschar'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersWoundEschar" id="">
                                                    </div>
                                                    <div class="col-lg-6">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Exudate'); ?></label>
                                                        <input type="text" class="form-control" name="MDOrdersWoundExudate" id="">
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Slough'); ?></label>
                                                        <select class="form-control" name="MDorderWoundSlough" id="MDorderWoundSlough">
                                                            <option value="" selected>Choose...</option>
                                                            <option value="Tan">Tan</option>
                                                            <option value="Grey">Grey</option>
                                                            <option value="Green">Green</option>
                                                            <option value="Yellow">Yellow</option>
                                                            <option value="White">White</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Present'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Color'); ?></label>
                                                        <select class="form-control" name="MDorderNecroticTissueColor" id="">
                                                            <option value="" selected>Choose...</option>
                                                            <option value="Leathery">Leathery</option>
                                                            <option value="Black">Black</option>
                                                            <option value="Brown">Brown</option>
                                                            <option value="Tan">Tan</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Drainage'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Type'); ?></label>
                                                        <textarea class='form-control' name='MDORDERWoundDrainageType' id=''></textarea>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Rate'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Light" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Light
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Modarate">
                                                            <label class="form-check-label" for="NO">
                                                                Modarate
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Heavy">
                                                            <label class="form-check-label" for="NO">
                                                                Heavy
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Amount'); ?></label>
                                                        <textarea class='form-control' name='MDORDERWoundDrainageAmount' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Bed Appearance'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Beefy" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Beefy
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Pink">
                                                            <label class="form-check-label" for="NO">
                                                                Pink
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Yellow">
                                                            <label class="form-check-label" for="NO">
                                                                Yellow
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Black">
                                                            <label class="form-check-label" for="NO">
                                                                Black
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Tunneling'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundTunnelling" id="radio" value="Yes" checked>
                                                            <label class="form-check-label" for="YES">
                                                                Yes
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="woundTunnelling" id="radio" value="No">
                                                            <label class="form-check-label" for="NO">
                                                                No
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                                        <textarea class='form-control' name='woundTunnelingComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Redness At Site'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MDOrdersWoundRednessAtSiteComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Odor'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MDOrdersWoundOdorComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Swelling'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MDOrdersWoundSwellingComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Wound Pain'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MDOrdersWoundPainComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Patient Independent In Wound Care'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Patient Is Willing To Learn'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-2">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Caregiver Is Willing To Learn'); ?></label>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="radio" value="YES" checked>
                                                            <label class="form-check-label" for="YES">
                                                                YES
                                                            </label>
                                                        </div>
                                                        <div class="form-check">
                                                            <input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="radio" value="NO">
                                                            <label class="form-check-label" for="NO">
                                                                NO
                                                            </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MDOrdersCaregiverIsWillingToLearnComment' id=''></textarea>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                        <textarea class='form-control' name='MdOrdersLastComment' id=''></textarea>
                                                    </div>
                                                    
                                                    
                                                    <div class="col-lg-5">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
                                                        <input type="text" class='form-control' name='MdOrdersCaregiver' id=''>
                                                    </div>
                                                </div>
                                            </div>
                              </div>
                            </div>
                          </div>   


                                  <div class="card">
                                    <div class="card-header" id="headingTwentyTwo">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyTwo" aria-expanded="false" aria-controls="collapseTwentyTwo">
                                          <h3 class="font-weight-bold">PROGRESS TOWARDS GOALS</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseTwentyTwo" class="collapse" aria-labelledby="headingTwentyTwo" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-5">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
                                                    <textarea class='form-control' name='ProgressTowordsGoals' id=''></textarea>
                                                </div>
                                                
                                                <div class="col-lg-5">
                                                    <label for="exampleInputEmail1" ><?php echo lang('CARE PLAN REVIEW DISCLOSURE'); ?></label>
                                                    <span>(Review HHA Care Plan and advise HHA to report any chages in conditions to nurse.  In case of emergency call 911)</span>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="checkbox" name="PogToGoalCArePlanReviewDisclouser" id="radio" value="YES">
                                                        <label class="form-check-label" for="YES">
                                                            YES
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-5">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Care Plan Details'); ?></label>
                                                    
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Accidents/Injury" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Accidents/Injury
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Body Mechanics and Transfer Techniques" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Body Mechanics and Transfer Techniques
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Complaints of Pain" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Complaints of Pain
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Skin Flushed and Hot" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Skin Flushed and Hot
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Nausea/Vomiting" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Nausea/Vomiting
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Nausea/Vomiting" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Developing Wound or Sore
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Skin Pale and Sweating" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Skin Pale and Sweating
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Change in Mental Status" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Change in Mental Status
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Dizziness/Headaches
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Shortness of Breath
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Slurred Words
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Diarrhea
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-3">
                                                    <label for="exampleInputEmail1" ><?php echo lang("Fall Precautions"); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="High" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Mild
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="Moderate">
                                                        <label class="form-check-label" for="NO">
                                                            Moderate
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="High">
                                                        <label class="form-check-label" for="NO">
                                                            High
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-8">
                                                    <div class="row">
                                                        <div class="col-lg-6">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Weight Gain Amount'); ?></label>
                                                            <input type="text" class="form-control" name="PogToGoalweightGainAmount" value="">
                                                        </div>
                                                        
                                                        <div class="col-lg-6">
                                                            <label for="exampleInputEmail1" ><?php echo lang('Weight Gain in days'); ?></label>
                                                            <input type="text" class="form-control" name="PogToGoalweightGainAmountIndays" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Temperature More Than'); ?></label>
                                                    <div>(Measured in Degrees fahrenheit)</div>
                                                    <input type="text" class='form-control' name='PogToGoalTemperatureMoreThan' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Pressure Ulser Risk'); ?></label>
                                                    
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Risk" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Risk
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Moderate" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Moderate
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="High" checked>
                                                        <label class="form-check-label" for="YES">
                                                            High
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Very High" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Very High
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-5">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Constipation'); ?></label>
                                                    <div>No Bowel Movement after (X) days</div>
                                                    <input type="text" class='form-control' name='PogToGoalConstipation' id=''></text>
                                                </div>
                                            </div>
                                        </div>
                                      </div>
                                    </div>
                                  </div>   




                                  <div class="card">
                                    <div class="card-header" id="headingTwentyThree">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyThree" aria-expanded="false" aria-controls="collapseTwentyThree">
                                          <h3 class="font-weight-bold">Skilled Nursing Interventions Summary/Follow-UP Plan</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseTwentyThree" class="collapse" aria-labelledby="headingTwentyThree" data-parent="#accordionExample">
                                      <div class="card-body">
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Other Current Services'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="OT" checked>
                                                        <label class="form-check-label" for="YES">
                                                            OT
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="PT" checked>
                                                        <label class="form-check-label" for="YES">
                                                            PT
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="ST" checked>
                                                        <label class="form-check-label" for="YES">
                                                            ST
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="LPN" checked>
                                                        <label class="form-check-label" for="YES">
                                                            LPN
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="Teacher" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Teacher
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="Other" checked>
                                                        <label class="form-check-label" for="YES">
                                                            Other
                                                        </label>
                                                    </div>
                                                    
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Review Of Emergency Plan'); ?></label>
                                                    <input type="text" class='form-control' name='reviewEmergencyPlan' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Review/Update Care Plan'); ?></label>
                                                    <input type="text" class='form-control' name='reviewOrupdateCarePlan' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Fall Prevention & Home Safety'); ?></label>
                                                    <input type="text" class='form-control' name='FallPreventionAndHomeSafety' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Seizure Precautions Observed '); ?></label>
                                                    <input type="text" class='form-control' name='SeizurePrecautionsObserved' id=''>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Standard Precautions Observed'); ?></label>
                                                    <input type="text" class='form-control' name='StandardPrecautionsObserved' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Maintain Aspiration Precaution'); ?></label>
                                                    <input type="text" class='form-control' name='MaintainAspirationPrecaution' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Equipment Checked'); ?></label>
                                                    <textarea type="text" class='form-control' name='EquipmentCheckedNotes' id=''></textarea>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-2">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Supplies Inventory Checked'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="SuppliesInventoryChecked" id="radio" value="YES" checked>
                                                        <label class="form-check-label" for="YES">
                                                            YES
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="SuppliesInventoryChecked" id="radio" value="NO">
                                                        <label class="form-check-label" for="NO">
                                                            NO
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Supplies Inventory Needed'); ?></label>
                                                    <textarea class='form-control' name='SuppliesInventoryNeededNotes' id=''></textarea>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Prepour Medication'); ?></label>
                                                    <input type="text" class='form-control' name='PrepourMedication' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Oxygen Safety'); ?></label>
                                                    <input type="text" class='form-control' name='OxygenSafety' id=''>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Supervise'); ?></label>
                                                    <span>(Caregiver Name)</span>
                                                    <input type="text" class='form-control' name='SuperviseCaregiverName' id=''>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="form-group">
                                            <div class="row">
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Care Giver Title'); ?></label>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="RN" checked>
                                                        <label class="form-check-label" for="YES">
                                                            RN
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="HHA" checked>
                                                        <label class="form-check-label" for="YES">
                                                            HHA
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="LPN" checked>
                                                        <label class="form-check-label" for="YES">
                                                            LPN
                                                        </label>
                                                    </div>
                                                    <div class="form-check">
                                                        <input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="PCA" checked>
                                                        <label class="form-check-label" for="YES">
                                                            PCA
                                                        </label>
                                                    </div>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
                                                    <textarea class='form-control' name='CaregiverTitleNotes' id=''></textarea>
                                                </div>
                                                <div class="col-lg-4">
                                                    <label for="exampleInputEmail1" ><?php echo lang('Revisit Date'); ?></label>
                                                    <input type="date" class='form-control' name='RevisitDateFlowupPlan' id=''>
                                                </div>
                                            </div>
                                        </div>

                                      </div>
                                    </div>
                                  </div>



                                  <div class="card">
                                    <div class="card-header" id="headingTwo">
                                      <h2 class="mb-0">
                                        <button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                          <h3 class="font-weight-bold">Authorities</h3>
                                        </button>
                                      </h2>
                                    </div>
                                    <div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
                                      <div class="card-body">
                                            <div class="form-group">
                                                <div class="row">
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('PRINT NAME'); ?></label>
                                                        <select class="form-control" name="caregiverPrintName" id="">
                                                            <option value="Hospital Bed">Hospital Bed</option>
                                                            
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('TITLE'); ?></label>
                                                        <select class="form-control" name="caregiverPrintTitle" id="">
                                                            <option value="RN">RN</option>
                                                            <option value="LPN">LPN</option>
                                                            <option value="HHA">HHA</option>
                                                            <option value="PCA">PCA</option>
                                                            <option value="Other">Other</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('CLINICIAN SIGNATURE'); ?></label>
                                                        <input type="text" class='form-control' name='clinicalSignature' id=''>
                                                    </div>
                                                    <div class="col-lg-3">
                                                        <label for="exampleInputEmail1" ><?php echo lang('Date'); ?></label>
                                                        <input type="date" class='form-control' name='clinicalSignatureDate' id=''>
                                                    </div>
                                                </div>
                                            </div>
                                      </div>
                                    </div>
                                  </div>



                            </div>


                                
                                <!-- <hr class="my-4">
                                <h3 class="font-weight-bold">SKIN</h3> -->
                                <!-- <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('skin'); ?></label>
                                            <div class="form-check form-check-inline">
                                                <select class="form-control" name="skin" id="">
                                                    <option value="Warm">Warm</option>
                                                    <option value="Dry">Dry</option>
                                                    <option value="Intact">Intact</option>
                                                    <option value="Rash">Rash</option>
                                                    <option value="Puritis">Puritis</option>
                                                </select>
                                            </div>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Describe'); ?></label>
                                            <div class="form-check form-check-inline">
                                                <input class="form-control" name="skinDescribe" type="text" id="" value="">
                                            </div>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Bruises Location'); ?></label>
                                            <div class="form-check form-check-inline">
                                                <input class="form-control" name="skinBruisesLocation" type="text" id="" value="">
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Surgical Site'); ?></label>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Clean" checked>
                                                <label class="form-check-label" for="YES">
                                                    Clean
                                                </label>
                                            </div>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Dry">
                                                <label class="form-check-label" for="NO">
                                                    Dry
                                                </label>
                                            </div>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Wound'); ?></label>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Clean" checked>
                                                <label class="form-check-label" for="YES">
                                                    Clean
                                                </label>
                                            </div>
                                            <div class="form-check">
                                                <input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Dry">
                                                <label class="form-check-label" for="NO">
                                                    Dry
                                                </label>
                                            </div>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                            <textarea class='form-control' name='skinComments' id=''></textarea>
                                        </div>
                                    </div>
                                </div> -->
                                <!-- <hr class="my-4">
                                <h3 class="font-weight-bold">CIRCULATION</h3> -->
                               
                                <!-- <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Peripheral Capillary Refill'); ?></label>
                                            <textarea class='form-control' name='peripheralCapilaryRefill' id=''></textarea>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Circulation Status'); ?></label>
                                            <div class="form-check form-check-inline">
                                                <select class="form-control" name="CirculationStatus" id="">
                                                    <option value="Good (less than 3 seconds)">Good (less than 3 seconds)</option>
                                                    <option value="Fair (3-5 seconds)">Fair (3-5 seconds)</option>
                                                    <option value="Poor (greater than 5 seconds)">Poor (greater than 5 seconds)</option>
                                                </select>
                                            </div>
                                        </div>
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
                                            <textarea class='form-control' name='Circulation_Comments' id=''></textarea>
                                        </div>
                                    </div>
                                </div> -->
                                
                                <!-- <hr class="my-4">
                                <h3 class="font-weight-bold">TRACHEOTOMY CARE</h3>
                                <div class="form-group">
                                    <div class="row">
                                        <div class="col-lg-4">
                                            <label for="exampleInputEmail1" ><?php echo lang('Tracheotomy Care Required'); ?></label>
                                            <select class="form-control" name="TracheotomyCareRequired" id="">
                                                <option value="Change">Change</option>
                                                <option value="Sterile">Sterile</option>
                                                <option value="Clean">Clean</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                                <hr class="my-4"> -->
                                
                       
                            
                            
                 
                            
                            
                            
                            <button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
                        </form>
                    </div>
                </div>
                </div>
            </div>
    
</section>
<!-- page end-->
</section>
</section>
</div>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script type="text/javascript"> /* future date dob not accept */
   
      $(document).ready(function () {
        // alert("dateSec");
       var todaysDate = new Date(); // Gets today's date
        
        // Max date attribute is in "YYYY-MM-DD".  Need to format today's date accordingly
        
        var year = todaysDate.getFullYear();                        // YYYY
        var month = ("0" + (todaysDate.getMonth() + 1)).slice(-2);  // MM
        var day = ("0" + todaysDate.getDate()).slice(-2);           // DD

        var maxDate = (year +"-"+ month +"-"+ day); // Results in "YYYY-MM-DD" for today's date 
        
        // Now to set the max date value for the calendar to be today's date
        $('.futDateNonAccept').attr('max',maxDate);
      
      });
  
</script>
<script type="text/javascript">
$('#respiratory').change(function(){
var respType = $(this).val();
if(respType == 'Breath Sounds')
{
document.getElementById("respBreathSound").style.display = "block";
}
else
{
document.getElementById("respBreathSound").style.display = "none";
}
})
$('#cardiovascular').change(function(){
var cvacType = $(this).val();
if(cvacType == 'Rhythm')
{
document.getElementById("CvacRhythm").style.display = "block";
document.getElementById("cvacEdema").style.display = "none";
}
if(cvacType == 'Edema')
{
document.getElementById("CvacRhythm").style.display = "none";
document.getElementById("cvacEdema").style.display = "block";
}
})
$('#therapy_type').change(function(){
var therapy_type = $(this).val();
$.ajax('initial_assessment/ajax_type_therapy', {
type: 'POST',  // http method
data: { val: therapy_type },  // data to submit
async: false,
success: function (data, status, xhr) {
// $('p').append('status: ' + status + ', data: ' + data);
// alert(data);
// msgs = data;
$("#typeAccValInp").html(data);
},
error: function (jqXhr, textStatus, errorMessage) {
// $('p').append('Error' + errorMessage);
alert("error duc");
}
});
});
$('#deviceAccessType').change(function(){
var dAccesType = $(this).val();
$.ajax('initial_assessment/ajax_type_device_access', {
type: 'POST',  // http method
data: { val: dAccesType },  // data to submit
async: false,
success: function (data, status, xhr) {
// $('p').append('status: ' + status + ', data: ' + data);
// alert(data);
// msgs = data;
$("#deviceAccessTypeDiv").html(data);
},
error: function (jqXhr, textStatus, errorMessage) {
// $('p').append('Error' + errorMessage);
alert("error duc");
}
});
});
$('#accessAssessmentDD').change(function(){
var accessAssessment = $(this).val();
$.ajax('initial_assessment/ajax_type_access_assessment', {
type: 'POST',  // http method
data: { val: accessAssessment },  // data to submit
async: false,
success: function (data, status, xhr) {
// $('p').append('status: ' + status + ', data: ' + data);
// alert(data);
// msgs = data;
$("#accessAssessmentDiv").html(data);
},
error: function (jqXhr, textStatus, errorMessage) {
// $('p').append('Error' + errorMessage);
alert("error duc");
}
});
});
$('#action').change(function(){
var accessAssessment = $(this).val();
$.ajax('initial_assessment/ajax_action_box', {
type: 'POST',  // http method
data: { val: accessAssessment },  // data to submit
async: false,
success: function (data, status, xhr) {
// $('p').append('status: ' + status + ', data: ' + data);
// alert(data);
// msgs = data;
$("#actionDiv").html(data);
},
error: function (jqXhr, textStatus, errorMessage) {
// $('p').append('Error' + errorMessage);
alert("error duc");
}
});
});
$('#pumpRate').change(function(){
var accessAssessment = $(this).val();
$.ajax('initial_assessment/ajax_pump_rate', {
type: 'POST',  // http method
data: { val: accessAssessment },  // data to submit
async: false,
success: function (data, status, xhr) {
// $('p').append('status: ' + status + ', data: ' + data);
// alert(data);
// msgs = data;
$("#pumpRateDiv").html(data);
},
error: function (jqXhr, textStatus, errorMessage) {
// $('p').append('Error' + errorMessage);
alert("error duc");
}
});
});
</script>
<script>
/*tool tip section*/
$(document).ready(function(){
$('[data-toggle="tooltip"]').tooltip();
});
</script>

<script type="text/javascript">
function isNumberKey(evt){
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        return false;
    return true;
}
</script>

<script type="text/javascript">
function isCharKey(inputtxt){

    var letters = /^[A-Za-z]+$/;
   if(inputtxt.value.match(letters))
     {
      return true;
     }
   else
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     // alert("message");
     return false;
     }
}
</script>
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