<?php

use yii\helpers\Html;

/* @var $this yii\web\View */
/* @var $model backend\models\Dt143be */


?>

<table class="Table notbb norb nolb">
<thead>
<tr>
	<td colspan="2" rowspan="2">
		<?= $this->render('//common/_pdfheader.php', ['title' => 'Inline Track Welding Limited - MEDICAL SELF CERTIFICATION (DT143)']) ?>
	</td>
	<th class="DarkerBlue">Pad No</th>
</tr>
<tr>
	<td><?= $model->padno ?></td>
	
</tr>
<tr>
	<th colspan="3">For duties of a Safety Critical nature alertness and reasonable physical fitness are essential, it is therefore important to answer the following questions as accurately as possible. When you declare NO you are accepting a degree of responsibility for your own safety.</th>
</tr>
<tr>
	<th colspan="3">After reading the following questions carefully, indicate 'YES' or 'NO' and sign the declaration below to confirm that you have read and fully understood the questions on the form.</th>
</tr>
	
</thead>	
<tbody>

	<tr>
		<td>1</td>
		<td>Do you have Diabetes needing medication?</td>
		<td><?= $model->question1?></td>
	</tr>
	<tr>
		<td>2</td>
		<td>Do you suffer from Epilepsy or fits?</td>
		<td><?= $model->question2?></td>
	</tr>
	<tr>
		<td>3</td>
		<td>Do you suffer from Asthma ?</td>
		<td><?= $model->question3?></td>
	</tr>
	<tr>
		<td>4</td>
		<td>Have you ever had any heart related problems?</td>
		<td><?= $model->question4?></td>
	</tr>
	<tr>
		<td>5</td>
		<td>Have you ever had blackouts, recurrent dizziness or any condition which may cause sudden collaspe or incapacity?</td>
		<td><?= $model->question5?></td>
	</tr>
	<tr>
		<td>6</td>
		<td>Do you suffer from discomfort or pain in the chest or shortness of breath on exercise i.e. climbing a single flight of stairs?</td>
		<td><?= $model->question6?></td>
	</tr>
	<tr>
		<td>7</td>
		<td>Do you have difficulty in moving rapidly over short distances including slopes, steps or rough ground?</td>
		<td><?= $model->question7?></td>
	</tr>
	<tr>
		<td>8</td>
		<td>Would you have difficulty looking over either shoulder?</td>
		<td><?= $model->question8?></td>
	</tr>
	<tr>
		<td>9</td>
		<td>Do you have any difficulty with your eyesight? (simple problems needing glasses need not be included)</td>
		<td><?= $model->question9?></td>
	</tr>
	<tr>
	<td>10</td>

<td>Do you have trouble identifying colours correctly?</td>
<td><?= $model->question10?></td>
	</tr>
	<tr>
	<td>11</td>
<td>Do you wear contact lenses at any time?</td>
<td><?= $model->question11?></td>
	</tr>
	<tr>
	<td>12</td>
<td>Do you have any difficulty hearing normal conversations?</td>
<td><?= $model->question12?></td>
	</tr>
	<tr>
	<td>13</td>
<td>Have you used drugs of abuse within the last 12 months?</td>
<td><?= $model->question13?></td>
	</tr>
	<tr>
	<td>14</td>
<td>Have you had any alcohol related illnesses during the last 12 months?</td>
<td><?= $model->question14?></td>
	</tr>
	
</tbody>
</table>    

<table class="Table nolb norb notbb">
		<tr>
		<th class="DarkerBlue">Employee</th>
		<td><?= $model->employeel ? $model->employeel->fullname : '' ?></td>
		<th class="DarkerBlue">Signature</th>
		<td><?= HTML::IMG($model->signature, ['alt' => $model->employeel ? $model->employeel->fullname : '' ]) ?></td>
		<th class="DarkerBlue">Date</th>
		<td><?= $model->date ?></td>
	</tr>
</table>
    
