98 lines
3.7 KiB
Plaintext
98 lines
3.7 KiB
Plaintext
<div class="layout">
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<div class="main">
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<%- include("partials/page-header", {
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user,
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title: t.global.edit,
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subtitle: patient.firstname + " " + patient.lastname,
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showUserName: true,
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hideDashboardButton: false
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}) %>
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<div class="content">
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<%- include("partials/flash") %>
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<div class="container-fluid">
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<div class="card shadow mx-auto" style="max-width: 700px;">
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<div class="card-body">
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<% if (error) { %>
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<div class="alert alert-danger"><%= error %></div>
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<% } %>
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<form method="POST" action="/patients/update/<%= patient.id %>">
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<input type="hidden" name="returnTo" value="<%= returnTo || '' %>">
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<div class="row">
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<div class="col-md-6 mb-2">
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<input class="form-control" name="firstname"
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value="<%= patient.firstname %>"
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placeholder="<%= t.patientEdit.firstname %>" required />
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</div>
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<div class="col-md-6 mb-2">
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<input class="form-control" name="lastname"
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value="<%= patient.lastname %>"
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placeholder="<%= t.patientEdit.lastname %>" required />
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</div>
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</div>
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<div class="row">
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<div class="col-md-4 mb-2">
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<select class="form-select" name="gender">
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<option value=""><%= t.global.gender %></option>
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<option value="m" <%= patient.gender === "m" ? "selected" : "" %>>Männlich</option>
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<option value="w" <%= patient.gender === "w" ? "selected" : "" %>>Weiblich</option>
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<option value="d" <%= patient.gender === "d" ? "selected" : "" %>>Divers</option>
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</select>
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</div>
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<div class="col-md-8 mb-2">
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<input class="form-control" type="date" name="birthdate"
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value="<%= patient.birthdate ? new Date(patient.birthdate).toISOString().split('T')[0] : '' %>"
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required />
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</div>
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</div>
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<input class="form-control mb-2" name="email"
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value="<%= patient.email || '' %>"
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placeholder="<%= t.patientEdit.email %>" />
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<input class="form-control mb-2" name="phone"
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value="<%= patient.phone || '' %>"
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placeholder="<%= t.patientEdit.phone %>" />
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<input class="form-control mb-2" name="street"
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value="<%= patient.street || '' %>"
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placeholder="<%= t.patientEdit.street %>" />
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<input class="form-control mb-2" name="house_number"
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value="<%= patient.house_number || '' %>"
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placeholder="<%= t.patientEdit.housenumber %>" />
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<input class="form-control mb-2" name="postal_code"
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value="<%= patient.postal_code || '' %>"
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placeholder="<%= t.patientEdit.zip %>" />
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<input class="form-control mb-2" name="city"
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value="<%= patient.city || '' %>"
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placeholder="<%= t.patientEdit.city %>" />
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<input class="form-control mb-2" name="country"
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value="<%= patient.country || '' %>"
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placeholder="<%= t.patientEdit.country %>" />
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<textarea class="form-control mb-3" name="notes" rows="4"
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placeholder="<%= t.patientEdit.notes %>"><%= patient.notes || '' %></textarea>
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<button class="btn btn-primary w-100">
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<%= t.patientEdit.save %>
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</button>
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</form>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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