# along with Confetti. If not, see <http://www.gnu.org/licenses/>.
check(){ [ "$1" = "$2" ] && printf checked}
+[ -z $mpx[presctype] ] && mpx[presctype]=doctor_compulsory
cat <<END_HTML
<form class="prescription" action="?action=update_prescription" method="POST">
<input type="hidden" name="prescription" value="${mpx[prescription]}">
-<h1>$(l10n therapy_prescription)</h1>
+<label class=presctype>$(l10n doctor):</label>
+<input type=radio name=presctype id=doctor_selfpaid value=doctor_selfpaid $(check "$mpx[presctype]" doctor_selfpaid)>
+<label for=doctor_selfpaid>$(l10n selfpaid)</label>
+<input type=radio name=presctype id=doctor_private value=doctor_private $(check "$mpx[presctype]" doctor_private)>
+<label for=doctor_private>$(l10n private)</label>
+<input type=radio name=presctype id=doctor_compulsory value=doctor_compulsory $(check "$mpx[presctype]" doctor_compulsory)>
+<label for=doctor_compulsory>$(l10n compulsory)</label>
+<br>
+
+<label class=presctype>$(l10n dentist):</label>
+<input type=radio name=presctype id=dentist_selfpaid value=dentist_selfpaid $(check "$mpx[presctype]" dentist_selfpaid)>
+<label for=dentist_selfpaid>$(l10n selfpaid)</label>
+<input type=radio name=presctype id=dentist_private value=dentist_private $(check "$mpx[presctype]" dentist_private)>
+<label for=dentist_private>$(l10n private)</label>
+<input type=radio name=presctype id=dentist_compulsory value=dentist_compulsory $(check "$mpx[presctype]" dentist_compulsory)>
+<label for=dentist_compulsory>$(l10n compulsory)</label>
+<br>
+
+<label class=presctype>$(l10n noprescription):</label>
+<input type=radio name=presctype id=noprescription_selfpaid value=noprescription_selfpaid $(check "$mpx[presctype]" noprescription_selfpaid)>
+<label for=noprescription_selfpaid>$(l10n selfpaid)</label>
+<br>
+<label class=presctype>$(l10n altpractition):</label>
+<input type=radio name=presctype id=altpractition_selfpaid value=altpractition_selfpaid $(check "$mpx[presctype]" altpractition_selfpaid)>
+<label for=altpractition_selfpaid>$(l10n selfpaid)</label>
+<input type=radio name=presctype id=altpractition_private value=altpractition_private $(check "$mpx[presctype]" altpractition_private)>
+<label for=altpractition_private>$(l10n private)</label>
+<br>
+
+<fieldset class="baseinfo">
<label for="insurance">$(l10n insurance)</label>
<input id="insurance" name="insurance" value="${mpx[insurance]}" placeholder="$(l10n insurance)">
<br>
<label for="name">$(l10n name)</label>
-<textarea id="name" name="name" placeholder="$(l10n name)">${mpx[name]}</textarea>
-<br>
<label for="bday">$(l10n bday)</label>
+<br>
+<textarea id="name" name="name" placeholder="$(l10n name)">${mpx[name]}</textarea>
<input id="bday" name="bday" value="${mpx[bday]}" placeholder="$(l10n bday)">
<br>
<label for="date">$(l10n date)</label>
<input id="date" name="date" value="${mpx[date]}" placeholder="$(l10n date)">
+</fieldset>
+
+<fieldset class="misc">
+<h1 id="${mpx[prescription]}">$(l10n therapy_prescription)</h1>
-<br>
<label for="addcontrib">$(l10n addcontrib)</label>
<input id="addcontrib" name="addcontrib" value="${mpx[addcontrib]}" placeholder="$(l10n addcontrib)">
-<input type="checkbox" id="contribconfirm" name="contribconfirm" value="true" ${mpx[contribconfirm]:+checked}>
<label for="contribconfirm">$(l10n contribconfirm)</label>
+<input id="contribconfirm" name="contribconfirm" value="${mpx[contribconfirm]}" placeholder="$(l10n contribconfirm)">
+<input type="checkbox" id="contribreceipt" name="contribreceipt" value="true" ${mpx[contribreceipt]:+checked}>
+<label for="contribreceipt">$(l10n contribreceipt)</label>
+</fieldset>
+<input type="checkbox" id="prescreviewed" name="prescreviewed" value="true" ${mpx[prescreviewed]:+checked}>
+<label for="prescreviewed">$(l10n prescreviewed)</label>
+
+<fieldset class="catalogue">
<h2>$(l10n prescription_by_catalogue)</h2>
<input type="radio" id="prescfirst" name="prescno" value="first" $(check "$mpx[prescno]" first)>
<label for="prescfirst">$(l10n prescfirst)</label>
<br>
<input type="checkbox" id="report" name="report" value="true" ${mpx[report]:+checked}>
<label for="report">$(l10n report)</label>
+</fieldset>
-<br>
-<label for="remidy">$(l10n remidy)</label>
-<textarea id="remidy" name="remidy" placeholder="$(l10n remidy)">${mpx[remidy]}</textarea>
-<br>
+<fieldset class="description">
<label for="quantity">$(l10n quantity)</label>
-<input id="quantity" name="quantity" value="${mpx[quantity]}" placeholder="$(l10n quantity)">
-<br>
+<label for="remidy">$(l10n remidy)</label>
<label for="quantity_weekly">$(l10n quantity_weekly)</label>
+<input id="quantity" name="quantity" value="${mpx[quantity]}" placeholder="$(l10n quantity)">
+<textarea id="remidy" name="remidy" placeholder="$(l10n remidy)">${mpx[remidy]}</textarea>
<input id="quantity_weekly" name="quantity_weekly" value="${mpx[quantity_weekly]}" placeholder="$(l10n quantity_weekly)">
-<br>
-<label for="remidy1">$(l10n remidy)</label>
-<textarea id="remidy1" name="remidy1" placeholder="$(l10n remidy)">${mpx[remidy1]}</textarea>
-<br>
<label for="quantity1">$(l10n quantity)</label>
-<input id="quantity1" name="quantity1" value="${mpx[quantity1]}" placeholder="$(l10n quantity)">
-<br>
+<label for="remidy1">$(l10n remidy)</label>
<label for="quantity_weekly1">$(l10n quantity_weekly)</label>
+<input id="quantity1" name="quantity1" value="${mpx[quantity1]}" placeholder="$(l10n quantity)">
+<textarea id="remidy1" name="remidy1" placeholder="$(l10n remidy)">${mpx[remidy1]}</textarea>
<input id="quantity_weekly1" name="quantity_weekly1" value="${mpx[quantity_weekly1]}" placeholder="$(l10n quantity_weekly)">
<br>
+<p class="indicator_codes">
<label for="indicator">$(l10n indicator)</label>
<input id="indicator" name="indicator" value="${mpx[indicator]}" placeholder="$(l10n indicator)">
<br>
<label for="icd10">$(l10n icd10)</label>
<input id="icd10" name="icd10" value="${mpx[icd10]}" placeholder="$(l10n icd10)">
-
+</p>
<br>
-<input type="checkbox" id="prescreviewed" name="prescreviewed" value="true" ${mpx[prescreviewed]:+checked}>
-<label for="prescreviewed">$(l10n prescreviewed)</label>
+<p class="indicator_reading">
+<label for="indicator_reading">$(l10n indicator_reading)</label>
+<textarea id="indicator_reading" name="indicator_reading" placeholder="$(l10n indicator_reading)">${mpx[indicator_reading]}</textarea>
+</p>
+</fieldset>
-<br>
+<fieldset class="controls">
<button type="submit" name="action" value="save">$(l10n save)</button>
<button type="submit" name="action" value="cancel">$(l10n cancel)</button>
<button type="submit" name="action" value="delete">$(l10n delete)</button>
+</fieldset>
</form>
END_HTML
projects / confetti / blobdiff