{% extends 'base_labTechnician.html' %}

{% block title %}form_cbc{% endblock %}

{% block content %}

		<div class="section section-custom billinfo"> 
			<!--section-title -->
			<h2>Please provide the values for the patient with :</h2><!--  section-title end -->
			<!-- section content start-->
			<div class="pmd-card pmd-z-depth">
				<div class="pmd-card-body">	
					<form class="form-horizontal" role="form" method="POST" action="{% url 'digiMED:lab_index' %}">
					{% csrf_token %}
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Patient ID</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="patient_id" value="{{ patient_id }}" id="patient_id" placeholder="{{ patient_id }}" type="text" readonly >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Date</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="date" value="{{ date }}" id="date" placeholder="{{ date }}" type="text" readonly >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">WBC (x10E3/uL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="wbc" name="wbc" placeholder="Normal Range : 4.0-10.5" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">RBC (x10E6/uL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="rbc" name="rbc" placeholder="Normal Range : 4.1-5.6" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Hematocrit (%)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="hematocrit" name="hematocrit" placeholder="Normal Range : 36-50" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Hemoglobin (g/dL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="hemoglobin" name="hemoglobin" placeholder="Normal Range : 12.5-17.0" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">MCV (fL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="mcv" name="mcv" placeholder="Normal Range : 80-98" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">MCH (pg)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="mch" name="mch" placeholder="Normal Range : 27-34" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">MCHC (g/dL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="mchc" name="mchc" placeholder="Normal Range : 32-36" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">RDW (%)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="rdw" name="rdw" placeholder="Normal Range : 11.7-15.0" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Platelets (x10E3/uL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="platelets" name="platelets" placeholder="Normal Range : 140-415" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Neutrophils (%)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="neurophils" name="neurophils" placeholder="Normal Range : 40-74" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Lymphs (%)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm"  id="lymphs" name="lymphs" placeholder="Normal Range : 14-46" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Monocytes (%)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm"  id="monocytes" name="monocytes" placeholder="Normal Range : 4-13" type="text" >
							</div>
						</div>
						<div class="form-group">
							<div class="col-sm-offset-2 col-sm-10">
								<button type="submit" name="data" id="data" value="Common Blood Count" class="btn btn-primary pmd-checkbox-ripple-effect">Submit</button>
							</div>
						</div>
					</form>
				</div>
			</div> <!-- section content end -->  
		</div>
{% endblock %}
