{% extends 'base_labTechnician.html' %}

{% block title %}form_metabolism{% 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">Glucose (mg/dL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="glucose" name="glucose" placeholder="Normal Range : 65-100" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Creatinine (mg/dL)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="creatinine" name="creatinine" placeholder="Normal Range : 0.8-1.4" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Sodium (mEq/L)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="sodium" name="sodium" placeholder="Normal Range : 133-146" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Potassium (mEq/L)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="potassium" name="potassium" placeholder="Normal Range : 3.5-5.3" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Chloride (mEq/L)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="chloride" name="chloride" placeholder="Normal Range : 97-110" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Carbon Dioxide (mEq/L)</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" id="carbon_dioxide" name="carbon_dioxide" placeholder="Normal Range : 18-30" 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="Metabolism Panel" class="btn btn-primary pmd-checkbox-ripple-effect">Submit</button>
							</div>
						</div>
					</form>
				</div>
			</div> <!-- section content end -->  
		</div>
{% endblock %}
