<form method="POST" action="" id="survey-form-send">
	
	<input type="hidden" name="data[survey_id]" value="<?php echo $this->view->survey_type_id; ?>">
	
	<div class="form-row">
		
		
		
		<?php $i=1; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="DISPNEA">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="">
		
		<?php $i++; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="PRESSIONE ARTERIOSA">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="">
		
		<?php $i++; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="PESO CORPOREO">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="Da controllare 3 volte a settimana">
		
		<?php $i++; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="CONGESTIONE PERIFERICA">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="">
		
		<?php $i++; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="SE PORTATORI DI ICD (PaceMaker)">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="">
		
		<?php $i++; ?>
		<input type="hidden" name="data[group][<?php echo $i; ?>][id]" value="<?php echo $i; ?>">
		<input type="hidden" name="data[group][<?php echo $i; ?>][label]" value="INDAGINI EMATOCHIMICHE">
		<input type="hidden" name="data[group][<?php echo $i; ?>][sublabel]" value="">
		
		<div class="form-group col-lg-12">
			<div class="strike-center strike-large"><span>DISPNEA</span></div>
		</div>
		
		<?php $i=0; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha affanno a riposo?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Ha affanno a riposo?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha affanno /tosse la sera quando si corica?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Ha affanno /tosse la sera quando si corica?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha bisogno di alzarsi nel cuore della notte per respirare meglio?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Ha bisogno di alzarsi nel cuore della notte per respirare meglio?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha affanno quando si lava e/o si veste?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Ha affanno quando si lava e/o si veste?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Riesce a fare 100/200/300 metri a piedi a passo normale senza affanno?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Riesce a fare 100/200/300 metri a piedi a passo normale senza affanno?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Riesce a fare le stesse cose che faceva l’ultima volta che ci siamo visti senza affanno?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="1">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Riesce a fare le stesse cose che faceva l’ultima volta che ci siamo visti senza affanno?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		
		<div class="form-group col-lg-12">
			<div class="strike-center strike-large"><span>PRESSIONE ARTERIOSA</span></div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">E' stata ridotta la terapia per via della pressione bassa?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="2">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="E' stata ridotta la terapia per via della pressione bassa?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">E' stata ridotta la terapia perché aveva capogiri o astenia?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="2">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="radio">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="E' stata ridotta la terapia perché aveva capogiri o astenia?">
			
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="1">
				<label class="form-check-label">Sì</label>
			</div>
			<div class="form-check form-check-inline">
				<input class="form-check-input" type="radio" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" value="0">
				<label class="form-check-label">No</label>
			</div>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Che valori di pressione aveva?</label>
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][group]" value="2">
			
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question_type]" value="text">
			<input type="hidden" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][question]" value="Che valori di pressione aveva?">
			
			<textarea class="form-control" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" rows="1"></textarea>
		</div>
		
		<div class="form-group col-lg-12">
			<div class="strike-center strike-large"><span>PESO CORPOREO</span></div>
		</div>
		
		
	</div>
	
	
	<hr>
	
	<div class="clearfix">
		<button type="submit" class="btn btn-primary btn-send-survey float-right"><?php echo _('Send'); ?></button>
	</div>

</form>