@include('pretests.patient_info')
<div class="row mt-4">
    <div id="form-date-group" class="form-group col-12 mb-4">
        <label for="form-date" class="col-form-label required">{{ __('pretests.form_date') }}</label>
        <div class="input-group date" id="form-date" data-target-input="nearest">
            <input type="text" name="form-date" class="form-control datetimepicker-input" data-target="#form-date" value="{{ date('Y-m-d')}}">
            <div class="input-group-append" data-target="#form-date" data-toggle="datetimepicker">
                <div class="input-group-text"><i class="fas fa-calendar"></i></div>
            </div>
        </div>
    </div>
    <div id="q1-group" class="form-group col-12 mb-4">
        <label for="q1" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q1') }}
        </label><br>
        <input type="text" name="q1" class="form-control">
    </div>
    <div id="q2-group" class="form-group col-12 mb-4">
        <label for="q2" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q2') }}
        </label><br>
        <select name="q2" class="form-control">
            @php $locations = __('pretests.laser_sessions.locations'); @endphp
            @foreach ($locations as $key => $location)
                <option value="{{ $key }}">{{ $location }}</option>
            @endforeach
        </select>
    </div>
    <div id="q3-group" class="form-group col-12 mb-4">
        <label for="q3" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q3') }}
        </label><br>
        <input type="text" name="q3" class="form-control">
    </div>
    <div id="q4-group" class="form-group col-12 mb-4">
        <label for="q4" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q4') }}
        </label><br>
        <input type="text" name="q4" class="form-control">
    </div>
    <div id="q5-group" class="form-group col-12 mb-4">
        <label for="q5" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q5') }}
        </label><br>
        <input type="text" name="q5" class="form-control">
    </div>
    <div id="q6-group" class="form-group col-12 mb-4">
        <label for="q6" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.q6') }}
        </label><br>
        <input type="text" name="q6" class="form-control">
    </div>
    <div id="q7-group" class="form-group col-12 mb-4">
        <label for="notes" class="form-label font-weight-bold">
            {{ __('pretests.laser_removal_questions.notes') }}
        </label><br>
        <textarea name="notes" class="form-control" rows="5"></textarea>
    </div>
    <x-admin.form.save-button title="{{ __('admin/common.buttons.save') }}" />


</div>