<?php
use yii\helpers\Html;
use yii\widgets\ActiveForm;
/* @var $this yii\web\View */
/* @var $model backend\models\Dt143be */
/* @var $form yii\widgets\ActiveForm */
?>
<div class="dt143be-form">
	<?php $form = ActiveForm::begin(); ?>
		<div class="card card-default">
			<div class="card-header">Update Medical Self Certifications</div>
			<div class="card-body">
				<div class="row">
					<div class='col-12 col-lg-2'>Id</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'id')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Created By</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'created_by')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Updated By</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'updated_by')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Deleted By</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'deleted_by')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Act Id</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'actid')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Related Id</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'relatedid')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Employee</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'employee')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Created at</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'created_at')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Updated at</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'updated_at')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Deleted at</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'deleted_at')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Job No</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'jobno')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Date</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'date')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Status</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'status')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Pad No</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'padno')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-2'>Signature</div>
					<div class='col-12 col-lg-4'><?= $form->field($model, 'signature')->textInput()->label(false) ?></div>
				</div>
				<div class="row">
					<div class='col-12 col-lg-6'>Do you have Diabetes needing medication?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question1')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you suffer from Epilepsy or fits?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question2')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you suffer from Asthma?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question3')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Have you ever had any heart related problems?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question4')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Have you ever had blackouts, recurrent dizziness or any condition which may cause sudden collaspe or incapacity?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question5')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you suffer from discomfort or pain in the chest or shortness of breath on exercise i.e. climbing a single flight of stairs?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question6')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you have difficulty in moving rapidly over short distances including slopes, steps or rough ground?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question7')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Would you have difficulty looking over either shoulder?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question8')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you have any difficulty with your eyesight? (simple problems needing glasses need not be included)</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question9')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you have trouble identifying colours correctly?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question10')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you wear contact lenses at any time?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question11')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Do you have any difficulty hearing normal conversations?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question12')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Have you used drugs of abuse within the last 12 months?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question13')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'>Have you had any alcohol related illnesses during the last 12 months?</div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question14')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question15')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question16')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question17')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question18')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question19')->textInput()->label(false) ?></div>
					<div class='col-12 col-lg-6'></div>
					<div class='col-12 col-lg-6'><?= $form->field($model, 'question20')->textInput()->label(false) ?></div>
					<div class="col-12 form-group">
						<?= Html::submitButton('Save', ['class' => 'btn btn-primary']) ?>
					</div>
				</div>
			</div>
		</div>
	<?php ActiveForm::end(); ?>
</div>
