MOZAMBICO/App/Views/Elements/Survey/ischemia.part.php

<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=0; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha dolore toracico?</label>
			
			<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 dolore toracico?">
			
			<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" for="inlineRadio1">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" for="inlineRadio2">No</label>
			</div>
		</div>
				
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Se sì</label>
				
			<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="Se sì">
			
			<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="A riposo">
				<label class="form-check-label">A riposo</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="Da sforzo">
				<label class="form-check-label">Da sforzo</label>
			</div>
		</div>
		
		<div class="form-group col-lg-12">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha affanno?</label>
			
			<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?">
			
			<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">Se sì</label>
			
			<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="Se sì">
			
			<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="A riposo">
				<label class="form-check-label">A riposo</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="Da sforzo">
				<label class="form-check-label">Da sforzo</label>
			</div>
		</div>
		
		<div class="form-group col-lg-12">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Sta assumendo tutte le medicine che le sono state prescritte?</label>
			
			<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="Sta assumendo tutte le medicine che le sono state prescritte?">
			
			<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">Se <span class="badge badge-secondary">No</span> quali farmaci ha sospeso:</label>
			
			<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="Se No quali farmaci ha sospeso:">
			
			<textarea class="form-control" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" rows="2"></textarea>
		</div>
		
		<div class="form-group col-lg-12">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Ha dolori muscolari, in particolare alle gambe?</label>
			
			<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 dolori muscolari, in particolare alle gambe?">
			
			<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">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Quale è il valore del suo colesterolo LDL?</label>
			
			<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="Quale è il valore del suo colesterolo LDL?">
			
			<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">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Assume farmaci che richiedono il piano terapeutico?</label>
			
			<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="Assume farmaci che richiedono il piano terapeutico?">
			
			<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">Se <span class="badge badge-secondary">Sì</span> quale farmaco:</label>
			
			<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="Se Sì quale farmaco:">
			
			<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">
			<hr>
		</div>
		
		<?php $i++; ?>
		<div class="form-group col-lg-12">
			<label class="label-main-question">Quando scade il piano:</label>
			
			<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="Quando scade il piano:">
			
			<textarea class="form-control" name="data[list][<?php echo $this->view->survey_type_id; ?>][<?php echo $i; ?>][answer]" rows="1"></textarea>
		</div>
		
	</div>
	
	<hr>
	
	<div class="clearfix">
		<button type="submit" class="btn btn-primary btn-send-survey float-right"><?php echo _('Send'); ?></button>
	</div>
</form>